■    .  '■  1 1 '. ,  i 

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College  of  ^Ij^siicians;  antr  burgeons! 
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A  TREATISE 

on 

FRACTURES,  LUXATIONS, 

AND  OTHER 

AFFECTIONS  OF  THE  BONES, 
BY  P.  J.  DESAULT, 

SURGEON  IN  CHIEF  TO  THE  HOTEL-DIEU  OF  PARIS, 

WHEREIN  HIS  OPINIONS  AND  PRACTICE,  IN  SUCH  CASES, 
ARE  STATED  AND  EXEMPLIFIED. 

EDITED  BY  XAV.  BICHAT; 

WITH  PLATES. 


TRANSLATED  FROM  THE  FRENCH, 

BY  CHARLES  CALDWELL,  M.  D. 


WITH  NOTES,  AND  AN  APPENDIX  CONTAINING  SEVERAL 
LATE  IMPROVEMENTS  IN  SURGERY. 


PHILADELPHIA: 

PRINTED  BY  FRY  AND  KAMMERER,  L^TITIA  COURT,. 
1805. 


V^' 


District  of  Pennsylvania,  to  ivit: 

^>-^  BE  IT  REMEMBERED,  That  on  the  twentieth 
s  SEAL  ^  day  of  February,  in  the  twenty-ninth  year  of  the  inde- 

'^-'v^  pendence  of  the  United  States  of  America,  A.  D.  1 805, 
Charles  Caldwell,  M.  D.  of  the  said  district,  hath  deposited  in 
this  Office,  the  Title  of  a  Book,  the  Right  whereof  he  claims 
as  proprietor,  in  the  words  following  to  wit: 

"  A  Treatise  on  Fractures,  Luxations,  and  other  Affections 
"  of  the  Bones,  by  P.  J.  Desault,  surgeon  in  chief  to  tlie  Hotel- 
"  Dieu  of  Paris,  wherein  his  Opinions  and  Practice,  in  such 
*'  cases,  are  stated  and  exemplified.  Edited  by  Xav.  Bichat; 
"  with  Plates.  Translated  from  the  French,  by  Charles  Cald- 
"  well,  M.  D.  With  Notes,  and  an  Appendix  containing  several 
"  late  improvements  in  surgery." 

In  conforaaity  to  the  act  of  the  Congress  of  the  United  States, 
intituled,  "  An  act  for  the  encouragement  of  learning,  by  secur- 
ing the  copies  of  maps,  charts,  and  books,  to  the  authors  and  pro- 
prietors of  such  copies  during  the  times  therein  mentioned:" 
And  also  to  the  act,  entitled,  "  An  act  supplementary  to  an  act, 
entitled,  "An  act  for  the  encouragement  of  learning,  by  securing 
the  copies  of  maps,  charts,  and  books,  to  the  authors  and  propri- 
etors of  such  copies  during  the  times  therein  mentioned,"  and 
extending  the  benefits  thereof  to  the  arts  of  designing,  engraving 
and  etching  historical  and  other  prints." 

D.  CALDWELL, 
Clerk  of  the  District  of  Pennsylvania. 


CONTENTS. 


MEMOIR  I.                               PAGE 
On  the  Fracture  of  the  Condyls  of  the  lower  Jaw, 1 

MEMOIR  II. 

On  the  Fracture  of  the  Clavicle, 8 

Explanation  of  the  first  Plate, 39 

MEMOIR  III. 

On  the  Luxation  of  the  Clavicle, 41 

Luxation  of  the  Sternal  extremity, 42 

of  the  Humeral  extremity, 54 

MEMOIR  IV. 
On  Fractures  of  the  Acromion,  and  of  the  lower  angle  of 

the  Scapula, 57 

Fracture  of  the  Acromion, ib. 

of  the  lower  angle  of  the  Scapula, 63 

MEMOIR  V. 
On  the  Fractures  of  the  upper  end  or  neck  of  the  Humerus,    67 

MEMOIR  VI. 
On  the  Fracture  of  the  lower  extremity  of  the  Humerus, 
with  a  separation  of  the  Condyls, 90 

MEMOIR  VII. 
On  the  Luxation  of  the  Humerus, 102 

MEMOIR  VIII. 

On  the  Fracture  of  the  bones  of  the  Fore-arm, 146 

Fracture  of  the  Radius, 160 

of  the  Ulna, 1 6f 

I  of  the  Olecranon, 168 


MEMOIR  IX.                              PAGE 
Oh  the  Luxation  of  the  Fore-arm, 1 84 

MEMOIR  X. 

On  the  Luxations  of  the  Radius  over  the  Ulna, 199 

Luxation  of  the  lower  extremity  of  the  Radius  .  .  .  204 

.      MEMOIR  XI. 

On  the  Fractures  of  the  Thigh, ' 214 

Fractures  of  the  body  of  the  Ob  Femoris, 215 

of  the  upper  end  of  the  Os  Femoris,  .  .  .  258 

of  the  great  Trochanter, ib. 

of  the  neck  of  the  Os  Femoris, 260 

of  the  lower  extremity  of  the  Os  Femoris,  280 

E!splanation  of  tlie  second  Plate, 291 

Thoughts  on  Luxations  of  the  Os  Femoris  upward  .and 
forward, , 292 

MEMOIR  XII. 
On  spontaneous  Luxations  of  the  Os  Femoris, .  299 

MEMOIR  XIH. 
On  tlie  Fracture  of  the  Rotula, 304 

MEMOIR  XIV. 

On  the  foiTTiation  of  foreign  bodies  in  the  joint  of  the  knee,  325 
Observations  and  Reflections  on  forms  of  Apparatus*  for 
fractures  of  the  leg, 342 

*  (Apfiareil.)  I  am  fully  sensible  that  the  word  Apparatus, 
does  not,  according  to  the  common  acceptation  of  the  term, 
convey,  in  English,  precisely  the  same  ideas,  tliat  the  word 
'^'  appareil"  does,  in  French ;  but  it  certainly  approaches  much 
nearer  to  it  than  any  other  term  found  in  English  works  on  sur- 
gery. It  signifies  a  collection  or  assemblage  of  means,  used  for 
the  attainment  of  a  particular  end;  and  this  is,  in  substance, 
what  Desault  meant  by  the  term  "  apfiareil."  His  "  appai*eil" 
(apparel)  for  a  broken  bone  included  splints,  bandages,  bolsters, 
and  every  thing  else  necessary  for  retaining  the  fractured  end^- 


MEMOIR  XV.                             FAGE 
On  the  Division  of  the  Tendo  Achillis, 355 

MEMOIR  XVI. 
On  the  Fracture  of  the  Os  Calcis, 374 

MEMOIR  XVII. 
On  complicated  Luxations  of  the  Foot, 379 


APPENDIX. 

ARTICLE  I. 

Dr.  Physick's.  new  and  successful  method  of  treating  an 
old  and  obstinate  fracture  of  the  os  humeri, 403 

ARTICLE  II. 
An  account  of  Dr.  Physick's  improvement  of  Desault's 
apparatus  for  making  permanent  extension  in  oblique 
fractures  of  the  os  femoris, 407 

ARTICLE  III. 
Explanation  of  the  third  Plate, 409 

in  apposition.  The  English  reader  will  naturally  enough  annex 
the  same  ideas  to  the  word  Apparatus,  as  used  throughout  the 
present  work.  I  have,  therefore,  thought  proper  to  adopt  it,  ra- 
ther than  to  introduce  a  new  or  uncommon  term,  and  am  sure, 
that,  for  all  practical  purposes,  it  will  be  found  sufficiently  ex- 
pressive of  the  meaning  of  the  original.  And  I  am  much  m^ore 
solicitous  to  become  instrumental  in  givmg  some  aid  to  the  sur- 
geon in  the  practice  of  his  profession,  than  to  escape  the  censure 
of  the  fastidious  criti<i.  Te  aks. 


PREFACE 

BY  THE  TRANSLATOR. 


The  business  of  a  translator,  though  very 
limited  as  to  its  range,  may  be  extensive  and 
important  in  its  consequences,  and,  though 
humble  in  its  end,  is  oftentimes  extremely  diffi- 
cultin  its  nature.  Prohibited  from  adding  any 
thing  to,  or  in  any  measure  transgressing  the 
bounds  of,  the  meaning  of  his  original,  he  is 
obligated  to  interpret  that  meaning  with  faith- 
fulness and  accuracy.  In  this  latter  point  con- 
sists the  difficulty  of  his  task.  If  several 
different  readers  oftentimes  attach  as  many 
different  meanings  to  parts  and  sentences  of 
works  written  in  their  own  language,  how 
much  more  likely  will  this  be  to  occur  with 
respect  to  such  as  are  written  in  a  foreign  lan- 
guage? For  readers  to  diff'er  in  the  former 
case  is  common,  in  the  latter  unavoidable. 

The  translator  of  the  following  work  is  far 
from  affirming,  that  he  has  in  no  instance  de- 
viated from  the  meaning  of  his  original.  To 
hazard  an  assertion  like  this,  would  be  as  sum- 


Vlll 


ing  to  himself  more  than  is  consistent  with 
modesty  or,  perhaps,  with  truth.  He  trusts, 
however,  that  such  deviations  are  very  rare, 
that  if  they  do  occur  they  are  but  sUght  in 
themselves,  and  never  connected  with  facts  or 
principles  of  practical  importance.  He  can,  at 
least,  very  confidently  declare,  that  they  have 
never  been  the  offspring  of  carelessness  or 
design. 

Should  any  one  open  this  volume  in  quest 
of  the  flowers  of  fancy,  or  the  embellishments 
of  style,  he  will  close  it  again  without  being 
gratified.  Ambitious  only  of  communicating 
new  and  useful  matter,  and  too  intent  on  things 
to  be  in  any  measure  choice  of  his  words,  the 
celebrated  original  was  regardless,  perhaps  to 
a  fault,  of  the  ornaments  of  diction.  Rich  in 
the  resources  of  a  capacious  and  exalted  intel- 
lect, he  poured  forth  his  knowledge  like  pre- 
cious ore  from  the  mine,  leaving  to  others  of 
inferior  capacities  the  humbler  task  of  refining 
and  polishing  it. 

With  such  an  example  before  him,  the 
translator  thought  it  best  to  follow  in  some 
measure  the  footsteps  of  his  illustrious  guide, 
without  venturing  to  chalk  out  a  new  and  dif- 
ferent track  for  himself.  As  his  principal  ob- 
ject, throughout  the  work,  has  been  to  make 


IX 


himself  clearly  understood,  and  that  in  as  few 
words  as  practicable,  he  has  never  hesitated, 
when  they  came  in  competition,  to  sacrifice 
elegance  to  precision  and  ornament  to  perspi- 
cuity. He  has  even  in  some  instances  beeri 
guilty  of  intentional  tautology,  for  the  purpose 
of  rendering  his  meaning  the  more  clear  and 
definite.  For  this  he  flatters  himself  he  need 
offer  no  apology  to  those,  who  prefer  utility  to 
pleasure  and  sense  to  sovind.  And,  as  to  read- 
ers of  an  opposite  cast  of  mind,  should  any 
such  choose  to  sit  in  judgment  on  him,  he  nei- 
ther deprecates  their  censure  nor  courts  their 
approbation. 

A  circumstantial  analysis  of  the  following 
memoirs  would  constitute  a  paper  too  exten- 
sive to  be  introduced  here  in  the  form  of  a 
preface,  and  a  mere  outline  or  general  charac- 
ter of  them  would  be  altogether  "useless.  The 
translation  is  now  before  the  public,  and  every 
reader  must  judge  of  its  merit  for  himself. 
On  this  point  the  translator  will  only  observe, 
that  the  attention  which  he  has  been  necessa- 
rily led  to  bestow  on  the  work,  has  been  to 
him  the  best  school  of  surgery  he  ever  attend- 
ed, as  far  as  relates  to  affections  of  the  bones. 
Should  other  practitioners  throughout  the 
United  States  derive  equal  benefit  from  peru- 

1 


X 


sing  his  translation,  he  will  rejoice  in  a  con- 
sciousness of  having,  at  least  in  one  instance, 
been  of  service  to  his  country. 

Such  are  the  extent  and  importance  of  De- 
sault's  improvements  in  some  branches  of 
practical  surgery,  as  to  constitute  a  new  epoch 
in  the  history  of  the  profession.  His  different 
forms  of  apparatus  for  fractures  and  luxations 
are  certainly  more  rational  in  their  construc- 
tion, and  more  efficacious  in  their  action,  than 
those  of  any  other  writer.  But  their  excel- 
lence does  not  arise  from  these  circumstances 
alone.  Their  cheapness  and  simplicity,  taken 
in  conjunction  with  the  ease  and  quickness 
with  which  they  may  be  every  where  made  and 
applied,  greatly  enhance  their  value,  particu- 
larly to  practitioners  in  the  country.  If  they 
be  not  already  at  hand,  they  can  be  easily  pre- 
pared by  the  surgeon  or  his  assistants,  without 
any  material  loss  of  time.  The  sufferings  of 
the  patient,  therefore,  whatever  may  be  the 
form  of  fracture  or  luxation  under  which  he 
labours,  need  never  be  prolonged,  by  any  delay 
in  obtaining  the  necessary  apparatus.  It  is 
thus  that  the  means  and  processes  of  every  art 
become  simple  and  easy,  in  proportion  as  the 
art  itself  approaches  perfection:  and  thus  that 
the  truly  great  artist  is  known,  not  by  the 


XI 


multiplicity  and  the    complex   nature  of  his. 
forms  of  apparatus,  but  by  the  numerous  ends 
which  he   accomplishes   by  means   the   most' 
simple  and  easy  of  construction. 

Several  French  practitioners,  in  projecting 
improvements  on  the  forms  of  apparatus  of 
Desault,  have  evidently  rendered  them  more 
complex,  more  expensive,  and  therefore  more 
difficult  to  be  constructed  or  procured,  without 
adding  in  the  smallest  degree  to  the  efficacy 
of  their  action.  This  is  particularly  the  case 
with  respect  to  Boyer,  in  his  attempt  to  substi- 
tute a  new  apparatus  for  a  fractured  clavicle, 
in  place  of  that  invented  by  Desault.  The 
latter  can  be  constructed  in  a  very  few  minutes 
by  the  surgeon  or  one  of  his  assistants,  with- 
out any  expense,  whereas  the  former  must  be 
made  by  a  workman  employed  for  the  purpose, 
and  is  necessarily  attended  with  both  cost  and 
delay.  Nor  is  it  always  practicable,  particular- 
ly in  the  country,  to  procure  a  workman  capa* 
ble  of  making  this  apparatus.  But  this  is  not 
all.  On  Desault's  plan,  the  same  apparatus 
for  a  fractured  clavicle  wiH  fit,  and  may  be  ap- 
plied to,  persons  of  different  sizes  and  figures; 
whereas,  on  the  plan  of  Boyer,  each  patient 
must  have  an  apparatus  constructed  particu- 
larly for  himself.     No  practitioner,  therefore,. 


xu 

can  hesitate  a  moment  in  deciding  to  which  of 
these  two  forms  of  apparatus,  tibe  prefeence -is 
due..  .V-,..:,     -•"•.-:-••■>:. '^y 

Similar  remarks  may  be  made  respecting 
Boyer's  apparatus  for  making  permanent  ex- 
tension in  obHque  fractures  of  the  os  femoria. 
It  is  much  more  complex  and  difficult  to  he 
constructed  than  that  of  Desault.  Nor  does  it 
possess  a  single  advantage  over  it  as  improved 
by  Drs.  Physick  and  Hutchinson.  In  a  word, 
the  forms  of  apparatus  of  Eoyer  may  answer 
well  enough  in  hospitals  and  in  cities,  where 
the  expence  of  such  articles  is  not  much  regard- 
ed, and  where  workmen  to  make  them  can  be 
readily  procured.  But,  as  the  practitioner  in 
the  country  is  generally  obliged  to  be  himself 
the  constructor  of  the  forms  of  apparatus  which 
he  uses,  and  as  he  is  not  at  all  times  prepared 
to  meet  heavy  expenses,  it  is  to  those  recom- 
mended and  employed  by  Desault  that  he  must 
necessarily  have  recourse. 

With  these  remarks  the  translator  submits 
to  the  good  sense  and  candour  of  his  country- 
men the  following  sheets,  as  the  offspring  of 
som.e  of  his  hours  of  leisure  throughout  the 
winter.  He  hopes  that  the  appendix  subjoined 
by  himself  will  not  be  regarded  as  either  an 
useless  or  an  unpleasing  addition.    Every  na- 


XUl 


tivd  of  the  United  States,  whose  bosom  glov/:- 
as  it  ought,  with  that  noblest  of  passions,  the 
amor  patria,  will  witness  with  pride  and  ezulta- 
tion  the  improvements  that  are  daily  making  in 
the  arts  and  sciences,  by  the  industry  and  enter- 
prize  of  his  enlightened  countrymen.  Such  <i 
mind  will  enjoy  in  anticipation  the  glory  of  hh 
country,  at  that  period,  when  she  will  be  able 
to  reflect  back,  with  increased  splendour,  th( 
light  which  she  has  so  long  been  borrowing 
from  the  countries  of  Europe. 

The  translator  does  not  plead  the  want  ci 
time  as  an  apology  for  any  imperfections  or 
errors  which  his  translation  may  exhibit.  Yei 
he  believes  it  to  be  true,  that  had  he  had  more 
time  to  bestow  on  it,  he  could  probably  have 
rendered  it  more  worthy  of  public  patronage. 


A  TREATISE 


FRACTURES,  DISLOCATIONS,  he. 


MEMOIR  I. 


ON  THE  FRACTURE  OF  THE  CONDYLES  OF  THE 
LOWER  JAW. 

§1. 

1.  THE  lower  jaw,  a  kind  of  moveable  ham- 
mer, destined,  to  use  the  words  of  a  certain  physi- 
ologist, to  triturate  the  aliments  against  the  almost 
immoveable  anvil  of  the  upper  jaw^,  is  more  exposed 
to  the  action  of  external  bodies,  and  consequently 
to  fractures,  than  most  of  the  other  bones  of  the  face. 
But  all  parts  of  it  are  not  alike  subject  to  such  acci- 
dents. Common  in  its  body,  but  less  frequent  in 
its  branches  or  sides,  fractures  sometimes  occur  in 
the  two  processes  in  which  its  branches  terminate. 
One  of  these  processes,  concealed  by  the  zygoma, 
embosomed  in  the  temporal  muscle,  and  covered  by 
the  raasseter,  is  less  liable  to  fractures  than  the  other, 
which  serves  as  the  centre  of  the  motions  performed 
by  the  bone,  and  is  protected  externally  only  by  the 

parotid  gland, 

2 


§  II. 

2.  A  fracture  of  the  condyle  may  sometimes 
arise  from  a  counter-stroke,  as  when,  in  consequence 
of  some  external  force  being  applied  from  before 
backwards,  and  from  below  upwards  against  the 
chin,  this  process  is  di'iven  against  the  projectmg 
rim  of  the  glenoid  cavity ;  at  other  times  it  may  be 
the  effect  of  an  immediate  or  direct  stroke,  as  when 
a  body  in  motion  strikes  with  force  against  the  regi- 
on of  the  joint,  and  does  violence  to  that  portion  of 
the  bone. 

3.  But  in  whatever  manner  the  fracture  may  be 
produced,  it  generally  occurs  in  the  slender  part  of 
the  bone  which  supports  the  condyle,  below  the  in- 
sertion of  the  pterygoideus  extemus.  It  is  charac- 
terized by  a  pain  more  or  less  acute,  necessarily 
accompanying-  the  motions  of  the  jaw;  by  a  difficulty 
more  or  less  considerable,  in  the  performance  of 
these  motions;  by  a  crepitation,  oftentimes  distinct, 
when,  in  consequence  of  the  angle  of  the  jaw  being 
pushed  forward,  or  the  jaw  itself  alternately  depressed 
and  elevated,  the  sepai'ated  surfaces  rub  against  each 
other ;  by  an  inequality  of  surface  sometimes  per- 
ceptible directly  over  the  fractured  condyle ;  by  the 
ease  v/ith  which,  on  being  pushed  forv/ard,  it  may 
be  forced  into  the  depression  beneath  the  zygoma; 
and  by  its  remaining  stationary,  during  the  move- 
ments of  the  lower  javv^,  from  Avhich  it  is  sepai'ated. 
These  signs,  though  generally  characteristic,  are 
subject  to  an  uncertainty  proportioned  to  the  swell- 
ing that  occurs  in  the  part. 


4.  In  this  accident  a  displacement  is  almost  always 
produced  by  muscular  action.  The  pterygoideus 
extenius,  being  attached  to  the  condyle,  draws  it 
forward  and  upward,  towards  the  external  wing  of 
the  pterygoid  apophysis,  its  fixed  point  of  insertion. 
On  the  other  hand,  the  body  of  the  bone  is  left  be- 
hind, being  held  by  tlie  masseter  and  external  ptery- 
goid muscles,  the  course  of  which  is  opposed  to  a 
displacement  in  the  same  direction;  so  that  there 
always  exists  a  separation,  more  or  less  perceptible, 
between  the  two  fragments  of  bone, 

5.  Hence,  if  proper  means  be  not  used  to  restore 
the  contact  between  the  broken  ends  of  the  bone, 
the  following  consequences  will  be  likely  to  occur : 
Xst.  Their  reunion  will  be  tedious,  because  in  every 
bone  this  process  is,  in  point  of  rapidity,  inversely 
proportioned  to  the  separation  of  the  divided  sur- 
faces :  2dly,  This  reunion  may  even  entirely  fail  to 
take  place,  if  the  bone  be  subject  to  the  slightest 
movements,  as  I  have  witnessed  in  a  particular  case, 
where  the  condyle,  not  being  reunited  to  the  other 
part,  exfoliated,  and  was  in  part  discharged  through 
the  external  integuments:  3dly,  Under  such  circum- 
stances, the  callus  produced  in  the  process  of  healing, 
being  situated  near  to  the  joint,  and  rendered  irregu- 
lar and  deformed  by  the  separation  of  the  parts,  is  apt 
to  impede  muscular  action,  and  do  a  permanent  in- 
jury to  the  functions  of  the  jaM\ 


§  III. 

6.  As  the  whole  apparatus  in  this  case  consists 
in  a  passive  resistance  to  the  active  powers  employed 
in  producing  a  displacement,  it  follows  from  what 
has  been  said  (4),  that  the  bandage  intended  to  pre- 
vent this  displacement,  and  by  that  means  to  guard 
against  the  accidents  specified  above  (5),  ought, 
either  effectually  to  bring  back  to  its  natural  situation, 
the  condyle  which  is  dra^vn  forward,  or  pull  in  this 
last  direction  (that  is,  forward)  the  body  of  the  bone 
T't  hich  is  still  retained  in  its  usual  position,  in  order 
that  it  may  thus  be  brought  into  contact  with  the 
condyle. 

The  first  of  these  measures  is  impracticable,  in 
consequence  of  the  situation  of  the  condyles,  which 
ai^e  too  deeply  enveloped  by  the  sun-ounding  parts, 
and  offer  a  hold  too  small  to  be  acted  on.  The 
second,  therefore,  remains  to  be  adopted,  and  is  the 
m.ore  easily  executed,  in  as  much  as  the  angle  of  the 
jaw,  from  its  projecting  and  being  but  slightly 
covered  by  the  integuments,  may  without  difficulty 
be  directed  from  behind  forward  by  a  proper  force. 

7.  The  fingers  of  the  surgeon  temporarily  supply 
this  force,  at  the  time  of  reduction;  but  it  is  neces- 
sary that  it  should  be  permanently  kept  up  by  means 
of  the  apparatus.  This  end  is  attained,  in  the  folio w- 
mannerr 

Place  behind  the  angle  of  the  jaw,  which  must 
be  first  pushed  forward,  thick  compresses,  to  fill  up 
the  hollow  under  the  ear,  and  form  an  eminence 
higher  than  the  surface  of  the  surrounding  parts; 
pass  over  these  compresses,  in  an  oblique  manner, 


the  bandage  commonly  used  in  lateral  fractures  of 
the  bone,  the  application  of  which  must  in  this  case 
commence  on  the  sound  side. 

These  compresses,  being  more  projecting  than 
the  surrounding  surface,  will  necessarily  sustain  a 
greater  pressure,  because  the  compression  made  by 
a  bandage  is  in  proportion  to  tlie  projection  of  the 
part  on  which  it  is  applied.  Hence,  being  firmly 
supported,  they  will  retain  the  body  of  the  bone  in  a 
line  with  the  displaced  condyle  (4). 

8.  In  addition  to  this  mode  of  applying  the  ban- 
dage, it  is  necessary  that  the  fractured  bone  should 
be  kept  in  a  state  of  perfect  rest.  The  internal  ptery- 
goid and  masseter  muscles,  tending  by  their  contrac- 
tile efforts  to  draw  the  angle  of  the  jaw  backvv^ards, 
sometimes  overcome  the  resistance  of  the  apparatus, 
and,  by  producing  a  second  displacement,  give  rise 
to  the  accidents  formerly  mentioned  (5). 

Let  the  lower  jaw  be  now  brought  into  perfect 
contact  mth  the  upper  one,  and  not  separated  from 
it  during  the  first  few  days  after  the  injury,  except 
so  far  as  may  be  necessary  for  the  admission  of  nou- 
rishing broths.  Should  a  tooth  have  been  lost,  the 
space  which  it  occupied  will  furnish,  without  dis- 
turbing the  bone,  an  opening  for  the  conveyance  of 
nourishment  to  to  the  patient.  Let  talking,  laughing, 
and  every  thing  that  might  produce  a  separation  be- 
tween the  body  of  the  bone  and  the  condyle,  be  care- 
fully avoided.  The  further  treatment  of  the  accident 
should  be  such  as  is  generally  applicable  to  all  fi'ac- 
tures  of  bones,  and  need  not  be  at  present  particularly 
detailed. 


The  following  cases,  reported  by  citizen  Giraud, 
second  surgeon  to  the  Hotel-Dieu,  will  confirm  the 
advantages  of  this  mode  of  treatment. 

Case  I.  Margaret  Bessonet,  aged  thirty-four, 
was  admitted  into  the  hospital  on  the  10th  of  May, 
1791-  On  the  preceding  day  she  had  received  a  vio- 
lent fall  on  her  chin :  a  severe  pain,  and  a  preterna- 
tural mobility  in  the  left  side  of  the  jaw,  had  been  the 
immediate  consequences  of  the  accident :  from  these 
symptoms,  taken  in  conjunction  with  those  formerly 
mentioned  (3),  Desault  discovered  that  a  fracture  of 
the  condyle  existed,  which  he  reduced  and  support- 
ed in  the  usual  manner  (7). 

After  being  somewhat  uneasy  during  the  first  few 
days,  the  patient  became  reconciled  to  the  action  of 
the  bandage,  which,  by  inattention,  had  been  two  or 
three  times  disturbed  and  put  out  of  order,  but 
which,  by  being  cai'efully  reapplied,  and  aided  by 
the  necessary  precautions  (8),  restored  to  the  bone 
its  natural  form  and  solidity,  by  the  thirtieth  day,  and 
on  the  thirty- sixth  the  patient  was  discharged  per- 
fectly cured.  The  only  inconvenience  she  experi- 
enced, was  a  slight  difficulty  in  the  motions  of  the 
jaw,  an  effect  naturally  resulting  from  the  long  con- 
tinued inactivity  of  the  muscles,  but  which  was  soon 
removed  by  means  of  exercise. 

Case  II.  Claudius  Laurat,  aged  tw^enty- seven, 
fell  as  he  was  caiTying  a  heavy  burden.  In  his  fall  his 
chin  struck  with  violence  against  a  beam  that  lay  in 
his  way.  In  an  instant  he  experienced  a  sharp  pain 
in  his  right  temple,  and  found  it  almost  impossible  to 
move  his  javv%  Two  hours  afterwards  a  considerable 


swelling  appeared  in  the  part,  extending  from  the  an- 
gle of  the  jaw  above  the  ear.  The  patient  was  admitted 
into  the  Hotel-Dieu,  where  the  circumstances  of  the 
fall  and  the  symptoms  that  followed,  gave  satisfactory- 
evidence  of  a  fracture  of  the  condyle.  It  was  reduced 
and  supported  as  in  the  preceding  case.  On  the  day 
following,  the  swelling  was  removed,  doubtless  by 
means  of  the  compression  which  had  been  made  on 
it;  the  other  symptoms  (3),  hitherto  scarcely  percep- 
tible, became  more  obvious ;  the  bandage  was  re- 
applied, and  the  disease  terminated,  in  about  twenty- 
nine  davs,  in  the  same  manner  with  that  of  case  1« 


MEMOIR  II. 

ON   THE  FRACTURE   OF   THE    CLAVICLE. 

1.  Man  enjoys  an  advantage  which  nature  has 
bestowed  on  but  few  of  the  quadrupeds,  namely,  a 
power  of  moving  his  upper  extremities  in  every 
direction.  The  clavicle  being  a  kind  of  arch  placed 
between  the  breast  and  shoulder,  forms  a  centre, 
moveable  indeed  but  solid,  for  these  motions,  a  part 
of  which  can  no  longer  be  performed,  w^hen  this  arch, 
in  consequence  of  being  broken,  ceases  to  afford 
them  a  point  of  support.  Hence  it  follows,  that  the 
fracture  of  this  bone  may  be  said  to  reduce  the  indi- 
vidual who  sustains  it,  when  considered  in  relation 
to  its  functions,  to  a  level  with  that  numerous  divi- 
sion of  animals  that  are  destitute  of  clavicles. 

2.  Few  diseases  of  the  kind  are  more  frequently 
met  with  than  this.  The  natural  curve  of  the  clavi- 
cle, its  situation  immediately  under  the  skin,  the 
want  of  a  support  to  its  middle  part,  the  great  propor- 
tion of  spongy  substance  which  enters  into  its  com- 
position, the  projection  of  the  shoulder  exposing  it 
to  the  action  of  external  bodies ;  all  these  circum- 
stances concur  in  rendering  the  accident  frequent, 
pailiculaiiy  among  that  class  of  men  subject,  from 
their  occupations,  to  violent  exertions  of  the  upper 
extremities.  • 

Here  then,  more  than  in  the  generality  of  frac- 
tures, we  should  feel  an  interest  in  the  advancement 


of  the  art  of  surgery ;  and  yet,  having  liitherto  em- 
ployed in  it  but  feeble  means,  our  efforts  have  been 
attended  with  imperfect  success.  Hippocrates  has 
observed,  that  some  degree  of  deformity  almost  al- 
ways accompanies  the  reunion  of  a  fractured  clavi- 
cle; all  writers  since  his  time  have  made  the  same 
remark;  experience  has  confirmed  the  truth  of  it, 
and  as  much  time  has  been  spent  in  hypothetical 
speculations  to  explain  the  accident,  as  in  serious  in- 
quiries how  to  prevent  it.  At  length  Desault  proved 
that  a  feeble  and  unskilful  mode  of  treatment  was  the 
sole  cause  of  a  want  of  success,  and  that,  by  being 
more  correct  ai>d  judicious,  art  might  be  as  success- 
ful here,  as  in  other  fractures.  In  order  to  give  a 
correct  view  of  his  practice  in  this  disease,  I  will 
examine  the  causes,  varieties,  and  signs  of  a  frac- 
ture of  the  clavicle ;  the  accidents  of  which  it  is  sus- 
ceptible; the  mode  and  the  causes  of  the  displacement 
of  the  broken  ends  of  the  bone;  the  indications  that 
arise  out  of  those  causes,  and  the  manner  of  answer- 
ing these  indications  as  well  during,  as  after,  the  re- 
duction. 

OF   THE   CAUSES   AND  VARIETIES. 

S.  The  action  of  external  bodies  is  almost  the 
only  known  cause  of  this  fracture,  wliether  these  bo- 
dies strike  the  shoulder  with  violence,  or  the  shoul- 
der be  forcibly  di'iven  against  them.  But  this  action  is 
not  in  every  case  the  same;  its  application  is  most 
frequently  mediate  or  indirect,  but  is  sometim.es 
immediate  or  direct. 

3 


In  the  first  case  there  is  a  true  counter-stroke,  thfe 
ordinary  elFect,  either  of  a  severe  blow  on  the  point 
of  the  shoulder,  which  is  the  most  common  occur-^ 
rence;  or,  as  happens  less  frequently,  of  a  fall  on  the 
arm  when  it  is  extended  for  the  purpose  of  guard- 
ing the  body  from  the  force  of  the  accident.  Under 
these  circumstances,  being  pressed  between  the 
sternum,  which  makes  resistance,  and  the  body 
which  acts  on  its  extremity,  the  clavicle  is  bent  in 
that  direction  which  is  most  natural  to  it;  but,  not 
being  sufficiently  flexible,  it  gives  way  generally  in 
the  place  where  its  curvature  is  the  greatest.  Thus 
the  ribs  are  broken,  when  the  sternum,  by  being 
violently  driven  backward,  forces  them  to  bend  in 
the  centre  beyond  their  natural  flexibility. 

In  the  second  case,  the  fracture  occurs  at  thfe 
spot  where  the  stroke  is  given.  Here  the  momen- 
tum or  quantity  of  force  applied  on  the  bone,  sur- 
passing the  solidity  which  the  bone  possesses,  its 
continuity  is  necessarily  destroyed. 

4.  But  in  whatever  way  the  fracture  is  produced, 
it  is  either  oblique  or  transverse,  single  or  double,  in 
the  middle  or  towards  the  extremities  of  the  bone, 
simple  or  compound. 

An  oblique  fracture  is  most  frequently  the  effect 
of  a  counter -stroke ;  a  transverse  fracture  is  the  more 
common  result  of  the  immediate  action  of  external 
bodies  j  a  counter-stroke  seldom  produces  any  thing 
but  a  simple  fracture ;  while  compound  fractures  are 
generally  owing  to  a  direct  stroke.  The  one  produces 
a  solution  of  continuity  in  the  middle  of  the  bone, 
or  thereabout;   because  in  that  part  the  curvature 


11 

is  most  considerable.  The  otlier  is  almost  always 
th,e  cause  of  this  solution,  when  it  occurs  at  the  ex- 
extremities.  To  the  latter  alone,  is  a  double  divi* 
sioxi  to  be  attributed.  The  reason  of  these  differ- 
ences is  already  so  plain,  that  it  would  be  a  waste 
of  time  to  dwell  on  an  explanation  of  them. 

§111. 

OF  THE    SIGNS. 

5.  The  several  phenomena  that  attend  a  fracture 
of  the  clavicle,  taken  together,  leave  in  general  but 
little  doubt  as  to  its  existence,  particularly  when  the 
fracture  is  oblique.  As  is  the  case  in  most  other  in, 
stances  of  the  kind,  so  here,  an  acute  pain  is  felt  at  the 
instant  of  the  stroke ;  sometimes  a  cracking  of  the 
bone  is  distinctly  heard  by  the  person  injured ;  on 
every  occasion,  it  becomes  suddenly  impracticable 
to  perform  circular  or  rotatory  motions  with  the  arm ; 
motions  from  before  backwards  can  still  be  execu- 
ted, but  are  difficult  and  painful,  and,  as  I  have  al- 
ready observed  (1),  the  individual  injured  is  reduced 
to  the  class  of  animals  destitute  of  clavicles. 

Oftentimes  the  shoulder  of  the  injured  side,  be- 
ing more  or  less  depressed,  loses  its  level  with  the 
other.  It  is  also  evidently  drawn  forward  and  inward. 
The  distance  between  the  acromion  and  sternum,  on 
the  affected  side,  is  found  on  comparison,  to  be  evi- 
dently less  than  on  the  opposite  side.  In  almost 
every  case,  that  portion  of  the  fractured  bone,  which 
adheres  to  the  sternum,  forms  a  visible  protuberance 
above  and  on  the  inside  of  the  i^houlder. 


12 

6.  In  the  mean  time  the  pain  continues.  The  pain- 
ful drawing  or  dragging  occasioned  by  the  weight  of 
the  ai'm  forces  the  patient,  for  the  purpose  of  reUeving 
it,  to  bend  his  body  towards  the  side  affected,  and  in- 
cline his  head  in  the  same  direction.  This  forms  a  pe- 
cuhar  attitude ,  which  of  itself  was  frequently  sufficient 
to  disclose  to  Desault  the  nature  of  the  disease.  We 
have  oftentimes  witnessed  him  establishing  the  truth 
of  this  diagnostic,  by  merely  looking  at  patients  en- 
tering the  amphitheatre,  who  had  been  brought  thi- 
ther for  the  reduction  of  such  fractures. 

By  this  position,  the  pains  are  generally  relieved, 
because  the  arm  finds  some  degree  of  support;  but 
should  the  patient  wish  to  change  his  position,  or 
perform  any  paiticular  mxOtions,  the  pains  return 
almost  as  acutely  as  at  first. 

7.  If  to  these  signs,  v/hich  are  almost  all  of  them 
founded  in  reason,  we  add  those  that  are  stiil  more 
palpable  to  the  senses,  such  as  the  mobility  of  the 
two  broken  ends  of  the  bone;  the  crepitation  pro- 
duced by  their  friction  against  each  other;  the  de- 
pression felt  at  the  point  of  fracture,  by  passing  the 
fingers  over  the  upper  surface  of  the  bone;  and  the 
facility  of  restoring  to  it  its  natural  form  and  direc- 
tion, by  moving  the  shoulder  upwards,  outwards, 
and  backwards;  it  will  be  difficult  to  be  mistaken 
respecting  the  nature  of  this  fracture.  This  is  per- 
haps more  particularly  the  case,  v/hen  the  fracture  is 
oblique,  as  this  kind  offers  the  most  striking  diagnosis, 
and  cannot  be  involved  in  uncertainty,  unless  when 
a  considerable  swelling  occurs  in  the  parts  around  the 
fracture.    But,  even  then,  as  the  circumspection  of 


13 

the  practitioner  will  necessarily  direct  his  attention  to 
this  circumstance,  the  obscurity  of  the  signs  will  have 
no  unfavourable  influence  on  the  cure. 

8.  When  the  fracture  is  transverse,  there  is  some- 
times more  difficulty  attending  the  diagnosis.  The 
corresponding  inequalities  of  the  divided  surfaces 
may  mutually  penetrate  each  other  and  interlock, 
and  thus  prevent  a  displacement.  Does  any  uncer- 
tainty on  this  score  exist  ?  Placing  your  fingers  on  the 
two  extremities  of  the  bone,  order  an  assistant  to 
move  the  arm  in  every  direction,  and  the  motions 
will  be  communicated  to  the  clavicle ;  but,  if  a  frac- 
ture exist,  they  will  be  most  perceptible  in  the  frag- 
ment adjoining  the  shoulder,  and  will  separate  it  from 
that  attached  to  the  sternum.  This  method  will  sel- 
dom decieve  us,  is  easily  employed,  and  subjects  the 
patient  to  but  a  momentary  pain. 

UV. 

OF   ACCIDENTS. 

9.  We  do  not  generally  find  fractures  of  the  cla- 
vicle accompanied  by  such  accidents  as  the  anatomi- 
cal relations  of  the  parts  might  lead  us  to  apprehend. 
The  external  force  being  all  expended  in  fracturing 
the  bone,  extends  but  feebly  to  the  brachial  plexus, 
which  would  be  much  injured  by  the  shock,  were 
the- bone  to  yield,  without  breaking,  to  the  action  of 
external  bodies  striking  against  it.  Hence,  without 
doubt,  would  arise  serious  affections,  as  may  be  fairly 
inferred  from  the  analogy  of  blows  on  the  head  and 


H 

vertebral  eolumn,  and  as  is  indeed  confirmed  by 
^itain  cases  reported  by  Desault. 

Case  I.  Two  bricklayers  were  brought  to  the 
Hotel-Dieu,  who  had  met  with  similar  accidents.  A 
piece  of  timber,  thrown  from  a  building,  in  which 
they  were  engaged,  had  struck  them,  the  one  on  the 
external  part  of  the  left  clavicle,  the  other  about  the 
middle  of  the  right,  A  considerable  wound  pointed 
out  in  each  the  place  on  which  the  blow  had  been  re- 
eeived.  Bat  the  former,  having  escaped  a  fracture, 
experienced  nothing  but  an  acute  pain,  while  the 
second  had  the  bone  broken  in  two  places. 

The  customary  apparatus  was  applied  to  the  latter, 
^nd  the  treatment  which  we  shall  presently  describe, 
being  pursued,  the  result  was  that  complete  success 
which  never  failed  to  crown  the  attentions  of  Desault. 
In  the  other  patient  a  considerable  swelling  made  its 
appearance  the  day  after  the  accident.  On  the  third 
day  a  numbness  and  partial  loss  of  the  power  of  mo- 
tion occurred  in  the  arm  of  the  affected  side.  Soon 
afterwards  an  insensibility  came  on,  and  by  the  se- 
venth day,  the  paralysis  of  the  arm  was  complete.  It 
was  not  till  after  a  tedious  treatment,  an  account  of 
which  would  be  foreign  from  my  present  subject, 
that  the  limb  recovered  in  part  its  original  strength. 

From  whatever  cause  the  fracture  of  the  clavicle 
in  this  latter  patient  was  prevented,  it  is  evident,  that 
the  whole  of  the  force  employed  to  produce  the  frac- 
ture in  the  other,  acted  here  on  the  brachial  plexus, 
and  gave  rise,  by  means  of  concussion,  to  the  acci- 
dents which  followed. 


IB 

10.  The  axillary  artery,  though  innning  near  to 
the  clavicle,  in  common  with  the  brachial  nerves, 
-experiences,  notwithstanding,  less  frequently  than 
they  do,  injurious  effects  from  the  fracture  of  this 
bone.  I  know  not  of  any  instance  Where  a  puncturfe 
from  the  broken  ends  of  the  clavicle  has  produced  in 
this  artery  a  false  aneurism.  To  conclude,  like  all 
other  fractures,  that  of  which  we  are  now  treating, 
may  be  connected  with  wounds,  splinters,  &c.  But 
in  general,  as  Hippocrates  remarks,  the  fracture  of 
the  clavicle  assumes  in  common  cases  a  mild  aspect. 

OF  DISPLACEMENT. 

11.  Most  of  the  symptoms  formerly  mentioned 
(5  and  6)  as  accompanying  a  fracture  of  the  clavicle, 
are  evidently  the  result  of  a  displacement  of  its  bro- 
ken ends.  Yet  this  phenomenon,  taken  notice  of  l>y 
all  authors,  and  considered  by  them  as  a  necessary 
effect  of  the  disease,  does  not  occur  in  every  case  (8). 
There  are  instances,  in  cases  of  transverse  fractures, 
where  the  extremity  attached  to  the  shoulder,  has 
retained  its  natural  position.  Three  examples  of 
this  kind  occurred  in  the  Hotel-Dieu  in  the  course 
ofthe  year  1787. 

12.  Instances  have  also  been  known,  in  which  the 
sternal  fragment,  when  fractured  obliquely  upwards, 
has  supported  the  end  of  the  humeral  in  such  a  man- 
ner as  to  prevent  any  derangement.  Desault  was 
accustomed  to  relate  several  cases,  where  similar 
occurrences  took  place ;  but,   in  general,  this  state 


16 

of  things  is  rare,  in  comparison  with  that  in  which 
the  fi'aginents  lose  their  natural  level. 

Almost  always,  then,  there  is  more  or  less  of  a 
perceptible  overlapping  fcheiiauchementj  produced, 
either,  by  the  elevation  (a  circumstance  which  is 
very  rare)  of  the  external  fragment  over  the  internal; 
or,  (as  commonly  occurs)  by  the  depression  of  the 
former  beneath  the  latter. 

13.  Of  the  first  of  these  modes  of  displacement 
(a  mode  but  rai'ely  mentioned  by  authors)  a  few  ex- 
amples are  to  be  found  among  the  observations  of 
Desault,  one  of  wliich  he  has  recorded  in  his  journal. 
Hippocrates  speaks  of  the  phenomenon  as  a  thing 
that  was  familiar  to  him. 

14.  The  second  kind  of  displacement,  that  which 
we  constantly  find  in  practice,  and  which  the  laws 
of  muscular  action  render  almost  inevitable,  takes 
place  in  such  a  manner  that  the  shoulder  appears  to 
obey  the  impulse  of  two  powers,  one  of  which  draws 
it  downwards,  and  along  with  it  the  external  fi-ag- 
ment  of  the  clavicle,  which  is  displaced  by  this  pow- 
er in  the  direction  of  its  transverse  diameter,  or 
thickness.  The  other  power  approximates  the  shoul- 
der  to  the  breast,  and  draws  it  forward,  carrying 
along  with  it  the  same  fragment,  which  is  by  this 
means  displaced  in  a  longitudinal  direction. 

That  we  may  the  better  understand  them  and 
their  effects,  let  us,  in  our  minds,  separate  these  two 
powers,  although  they  ai'e  perfectly  simultaneous  in 
their  action.  A  knowledge  of  them  will  lead  us  to  a 
knowledge  of  the  resistances  which  ought  to  be 
©pposed  to  them.    But  let  us  first  remark,  that  the 


17 

humeral  fragment,  being  drawn  downward  and  in~ 
ward,  takes  sometimes  such  a  direction,  that  its 
internal  extremity  passes  backward  under  the  sternal 
fragment,  its  external  end  continuing  to  point  for- 
ward :  this  disposition  can  be  understood  from  its 
natural  direction. 

15.  The  first  of  these  powers,  namely,  that  which 
depresses  the  point  of  the  shoulder,  appears  to  have 
escaped  the  notice  of  the  ancient  physicians  of 
Greece,  who  attril;)uted  the  apparent  depression  of 
this  part,  to  the  elevation  of  the  sternal  fragment, 
and,  accordingly,  endeavoured  by  making  compres- 
sion on  the  latter,  to  restore  it  to  a  level  with  the 
other.  Hippocrates,  more  judicious  than  those  who 
had  preceded  him,  demonstrated  that  their  doctrine, 
false  in  its  principles,  was  still  more  dangerous  in  its 
consequences,  and  that  the  sternal  fragment  being 
immoveable,  lost  its  relative  position  with  respect  to 
the  humeral,  only  because  the  latter  was  depressed 
by  the  weight  of  the  arm.  This  doctrine  of  the  father 
of  physic  is  satisfactorily  proved,  by  a  comparison  of 
the  sound  shoulder  with  the  diseased  one,  and  has 
since  been  admitted  by  all  practitioners.  Indeed,  the 
mere  recollection  that  one  of  the  uses  of  the  clavicle 
is  to  support  the  shoulder  at  that  level  necessary  for 
the  performance  of  its  functions,  is  alone  sufficient 
to  convince  us,  that,  in  case  of  its  ceasing  to  fulfil 
that  office,  the  shoulder  "must  obey  the  laws  of  its 
own  gravity,  increased  by  that  of  the  hand  and  arm.. 

16.  The  illustrious  Petit,  and  with  him  Duvemey, 
in  acknowledging  this  cause  of  displacement,  have  ad- 
ded to  it  as  another  the  action  of  the  deltoid  muscle  on 

4 


IS 

the  external  end  of  the  bone ;  in  this  action,  the  end 
of  the  clavicle  is  the  moveable  point,  while  the  hu- 
merus affords  the  fixed  point.  But  how  can  wc 
admit  this  cause,  when  the  humeral  fragment,  in 
passing  under  the  sternal,  moves  in  a  backward 
direction  ?  So  far  is  the  deltoid  muscle  from  drawing 
the  bone  downward,  that  here  the  bone  rather  draws 
the  muscle  in  part  backward,  and  yet,  in  such  a  case, 
the  displacement  is  as  perceptible  as  in  any  other. 
Besides,  when  the  sternal  fragment,  broken  obliquely 
upwards,  supports  the  humeral  and  prevents  a  dis- 
placement, why  does  not  the  deltoid  produce  this 
displacement? 

It  is  then  in  the  weight  of  the  arm  and  shoulder 
alone,  that  we  must  look  for  the  passive  power, 
which  depresses  them,  and  which  produces  a  dis- 
placement in  the  direction  of  the  transverse  diameter 
or  thickness  of  the  clavicle. 

17.  A  second  power,  highly  active,  co-operates 
with  this.  I  allude  to  the  permanent  contraction  of 
the  muscles,  that  extend  from  the  breast  to  the  cla- 
vicle and  shoulder:  from  this  cause  arises  the  dis- 
placement in  the  longitudinal  direction  of  the  bone. 

The  pectoralis  major,  the  pectoralis  minor,  the 
subclavius,  the  serratus  major,  and  the  trapezius, 
unite  their  efforts  in  producing  this  displacement. 
These  muscles  are,  in  certain  respects,  antagonists 
to  each  other,  but  they  all  unite  in  drawing  the 
shoulder  forward  and  inward.  None  of  them  appears 
to  act  with  more  effect  than  the  pectoralis  major. 
To  this,  in  particular,  is  to  be  attributed  the  displace- 
ment in  a  forward  direction. 


19 

Except  in  the  instances  stated  above,  the  action 
of  the  muscles  is  not  immediate.  They  act  only 
secondarily  on  the  external  fragment,  which,  being 
stedfastly  attached  to  the  scapula  and  humerus,  is 
obedient  to  the  motions  impressed  by  the  muscles 
on  these  two  bones;  motions  Avhich,  in  a  sound  state, 
the  clavicle  has  a  power  of  controuling. 

18.  To  the  weight  of  the  lower  extremity  (15 
and  16),  and  the  spontaneous  action  of  the  muscles 
(17)  must  be  added,  as  another  cause  of  displace- 
ment, the  motions  which  are  communicated  to  the 
arm  by  external  bodies,  and  which,  being  imparted 
ultimately  to  the  clavicle,  derange  the  fragments,  by 
separating  them,  approximating  them,  or  making 
them  overlap  each  other,  according  to  the  direction 
in  which  they  act. 

19.  When  a  fracture  occurs  at  the  extremity  next 
the  shoulder,  no  displacement  of  the  fragments  in 
general  takes  place.  This  circumstance  is  attributed 
to  the  action  of  the  trapezius,  which  draws  each  frag- 
ment upwards  with  equal  force.  However  this  may 
be,  it  is  doubtless  to  such  cases  that  we  must  refer 
the  complete  cures,  obtained  mthout  any  retentive 
apparatus,  by  Gasparetti,  Brown,  and  other  -writers. 
Hence  also,  without  doubt,  arise  the  difficulties  ex- 
perienced by  certain  practitioners,  such  asDuvemey, 
with  respect  to  the  diagnosis  of  this  disease.  These 
fractures  may  be  mistaken  for  fractures  of  the  aero- 
mion,  being  situated  so  immediately  in  its  vicinity. 


20 

§  VI. 

OF   THE   REDUCTION- 

20.  On  looking  into  the  causes  of  that  displace- 
ment (15...  18),  so  common  in  fractures  of  the  cla- 
vicle, it  appears  that  in  almost  every  case,  the  exter- 
nal extremity  of  the  humeral  fragment  is  <irawn,  by 
a  double  power,  downward,  inward,  and  forward. 
Hence  it  follows,  1st.  That  the  resistance  opposed  to 
this  power,   by  the  means  used  for  the  purpose  of 
reduction,   and  the  retentive  apparatus  subsequently 
employed,  ought  to  be  directed  upward,  backward, 
and  outward,  these  directions  being  the  reverse  of 
those  in  which  the  powers  of  displacement  act :  2dly. 
That,  in  as  much  as  these  powers,  viz.  the  weight 
of  the  parts  and  the  action  of  the  muscles,   are   in 
constant  operation,  and,   besides,  as  the  motions  of 
the  arm  are  continually  disturbing  the  fragments  of 
the  bone,  the  apparatus  ought  to  be  equally  constant  in 
its  action,  and  should  keep  up,  "\\dthout  any  remis- 
sion, the  effect  produced,  at  first,  by  the  means  of 
reduction.     This  principle  is   applicable  to  every 
case,  and  ought  to  be  the  standard  of  comparison,  for 
determining  the  advantages  or  disadvantages  of  dif-" 
ferent  bandages,  and  processes  for  the  reduction  of 
fractures  of  the  clavicle. 

21.  But  we  ai^e  not  to  suppose,  that  these  pro- 
cesses have  heretofore  manifested  an  exact  applica- 
tion of  this  rule.  Hippocrates  directed  to  press  the 
arm  close  to  the  ribs,  and  at  the  same  time  to  push 
it  upwards,  in  such  a  manner,  as  to  make  the  shoul- 
der appear  as  sharp  and  pointed  as  possible.    Hence 


21 

his  precept,  to  lay  the  patient  downon  his  back,  the 
back  being  supported  by  some  projecting  body,  and 
then  to  press  the  shoulders  backward;  hence  again, 
when  the  humeral  fragment  is  diawn  inward,  his 
advice  to  press  the  elbow  close  to  the  breast.    This 
twofold  expedient  was  attended  with  great  diffi- 
culties,  even  under  the  direction  of  the  father  of 
medicine.     Celsus  only  copied  Hippocrates,  adding 
nothing  whatever  to  his  mode  of  practice.    Paul  of 
Egina,  more  judicious  in  this  case,  conceived,  that 
for  the  purpose  of  forcing  the  shoulder  outward,  and 
rendering  it,   agreeably  to  the  idea  of  Hippocrates, 
very  projecting  and  sharp,  it  would  be  advisable  to 
place  the  fulcrum  or  point  of  support,  not  in  the 
middle  of  the  back,  but  under  the  arm-pit.  A  wool- 
len ball  w^as  employed  by  him  for  this  purpose,  a 
practice  which  would,  at  once,  have  carried  the  art 
near  to  perfection,  if,  after  being  employed  to  reduce 
the  fragments,  this  process  had  been  continued  for 
the  purpose  of  retaining  them  in  apposition. 

22.  No  new  method  distinguished  the  surgery  of 
the  Arabians.  It  is  necessary  to  com.e  down  to  the 
time  of  Guy  of  Chauliac,  before  we  meet  with  the 
method  which  is  almost  universally  adopted  at  pre- 
sent, and  which  consists  in  placing  between  the 
shoulders,  the  knee  of  an  assistant,  whose  hands  are 
to  be  employed  in  drawing  them  forcibly  backwards. 
But  it  is  evident  that  this  is  only  doing,  while  the 
patient  is  in  an  erect  position,  what  Hippocrates  did, 
after  having  laid  him  with  his  back  on  a  projecting 
body.  Here,  then,  the  art  seems  to  have  degenerated, 
after  the  time  of  Paul  of  Egina:  and,  indeed,  on 


22 

comparing  this  process  with  the  general  principles 
already  established  (20),  it  will  be  immtdiately 
perceived,  that  the  powers  of  replacement  do  not 
here  act  in  an  opposite  direction  to  those  of  displace- 
ment. 

Hence  the  diiliculties  of  reduction,  the  time  spent 
in  the  operation,  and  the  sufferings  by  which  it  was 
Sure  to  be  accompanied.  The  fragments  were 
brought  together,  it  is  true ;  but  it  was  only  by  vary- 
ing the  movements,  and  changing  their  direction, 
^at  the  point  of  contact  was  ultimately  found. 

23.  Desault  conceived,  in  the  year  1768,  that  to 
reduce,  in  the  most  effectual  manner,  a  fracture  of 
the  clavicle,  it  was  necessaiy  not  only  to  push  the 
shoulder  backward  and  upward,  as  was  commonly 
done,  but,  above  all,  to  force  it  outward,  and  that  the 
power  destined  to  draw  it  in  this  latter  direction, 
ought  to  act  horizontally,  according  to  the  course  of 
the  clavicle,  in  the  same  way,  as,  in  an  oblique  frac- 
ture of  the  thigh  or  leg,  the  extension  for  replacing 
the  fragments  is  made  in  the  direction  of  the  bone. 

24.  As  the  union  of  the  humerus  to  the  clavicle, 
by  means  of  the  scapula,  communicates  to  the  one 
the  movements  of  the  other,  it  is  easy,  by  placing 
the  ball  used  by  Paul  of  Egina,  under  the  arm-pit, 
to  convert  the  arai  into  a  lever  of  the  first  kind.* 

*  That  form  of  lever,  where  the  weight  to  be  raised  or  the 
resistance  to  be  overcorae,  is  at  one  end,  the  force  at  the  other, 
and  the  fulcrum  or  prop  between  them.  This  form  is  well  repre- 
sented by  the  handle  of  a  pump,  where  the  pistcai  is  the  weight 
or  resistance,  the  hand  of  the  drawer  of  v/ater  the  force,  and 
the  iron  pin,  on  which  the  handle  works,  the  fulcrum  or  prop. 

Traxs. 


23 

The  lower  extremity  of  the  arm  being  then  pressed 
towards  the  body,  the  upper  end  is  separated  from 
it,  and  becomes,  with  regard  to  the  clavicle,  what 
the  efforts  of  an  assistant  who  makes  the  extension, 
in  a  fracture  of  the  leg,  are  to  the  foot  of  the  patient. 
The  mode  of  reduction  being  established,  it  was 
necessary,  in  the  next  place,  to  invent  a  bandage,  cal- 
culated to  retain  the  broken  ends  of  the  bone  in  con- 
tact. Desault  thought  it  practicable  to  unite  these  two 
points  of  treatment,  in  the  same  process,  that  is  to  say, 
to  reduce,  and  at  the  same  time  to  retain  the  frac- 
ture. Here  the  art  is  indebted  to  him  for  an  improve- 
ment, which,  I  will  venture  to  say,  carries  it  near  to 
perfection.  To  judge  of  this,  it  will  be  necessary 
only  to  take  a  hasty  survey  of  the  different  kinds  of 
apparatus  proposed  by  different  writers. 

§VII. 

OF  THE  MEAXS  OF  RETAINING  A  REDUCTION. 

25.  Here  all  authors  seem  to  have  been  directed 
by  the  same  principle.  This  is  to  keep  the  shoulder 
of  the  affected  side,  1st,  drawn  forcibly  backwards, 
2dly,  approximated  towards  the  shoulder  of  the  sound 
side.  Such  was  the  practice  of  the  Greek  physici- 
ans, whom  we  have  seen  in  common  with  Hippocra- 
tes, Celsus,  and  Paul  of  Egina,  employing  a  kind  of 
bandage,  varied  in  its  form,  according  to  the  dis- 
placement  it  was  intended  to  remedy. 

Above  all  others,  we  find  an  application  of  this 
principle,  in  the  figure  of  8  bandage,  a  particular 
form,  vy^hich  was  employed  in  practice  by  Aibulasis, 


an  Arabian,  and  afterwards  by  his  countrymen,  as 
well  as  by  Lanfranc,  Guy  of  Chauliac,  and  their  co- 
temporaries.  The  use  of  this  bandage  was  continued 
by  Pare  and  his  successors,  and  has  been  lately 
modified  by  several  authors,  such  as  Heister,  Petit, 
Brunninghausen,  &c. 

26.  But  under  whatever  form  it  shows  itself,  its 
action  is  always  the  same,  and  always  insufficient. 
On  comparing  its  effect  with  the  general  principle, 
on  which  every  apparatus  for  the  clavicle  should  be 
constructed  (20),  we  percieve,  that  it  by  no  means 
answers  the  threefold  indication,  of  retaining  the 
shoulder  backward,  outward,  and  upward. 

27.  In  relation  to  carrying  the  shoulder  backward 
it  loses  half  of  its  effect,  because,  its  force  being  de- 
composed (so  to  speak)  by  the  obliquity  of  its  di- 
rection, is  divided  into  two  channels.  One  of  these 
runs  parallel  to  the  shoulder  and  acts  to  no  purpose, 
while  the  other,  being  perpendicular  to  it,  is  alone 
effective ;  hence  it  must  act  with  a  force  equal  to  10, 
in  order  to  produce  an  effect  equal  to  5. 

28.  The  indication,  to  draw  the  humeral  frag- 
ment outward,  far  fi'om  being  fulfilled,  is  here  diame- 
trically counteracted.  The  scapula,  being  approxi- 
mated to  that  of  the  opposite  side,  draws  the  hume- 
ral fragment  towards  the  trunk,  making  it  underlap 
the  internal  one,  and,  in  this  respect,  the  figure  of  8 
bandage  acts  posteriorly  in  precisely  the  same  man- 
ner, during  the  treatment,  that  the  contractions  of 
the  muscles  did  anteriorly  before  the  reduction. 

29.  Should  the  shoulder  be  supported,  at  such  an 
elevation,  as  might  have  a  constant  tendency  to  de- 


25 

stroy  the  influence  of  its  own  gravity?  this  is  evi- 
dently prevented  by  the  very  obUque  direction  of 
the  turns  of  the  bandage.  Suspending  the  arm  in  a 
sling,  is  the  only  way,  in  which  that  end  can  be  at- 
tained. But  does  this  mode  always  possess  sufficient 
firmness  and  stability?  The  arm,  not  being  here  suf- 
ciently  fixed,  maybe  constantly  in  motion,  which,  by 
deranging  its  situation,  must  communicate  very  trou- 
blesome and  injurious  movements  to  the  fragments 
of  the  clavicle.  One  of  the  principal  faults  of  ail  ban- 
dages consists,  in  not  preventing  these  movements, 
by  restraining  the  movements  of  the  arm. 

To  the  other  disadvantages  of  this  mode,  need  I 
add  that  of  its  making,  by  the  turns  of  the  bandage, 
an  undue  compression  on  the  projecting  edges  of 
the  arm-pit,  and  producing  thereon  troublesome  and 
painful  excoriations? 

30.  From  the  want  of  a  mutual  correspondence 
and  fitness  between  the  indications  already  enume- 
rated (20),  and  the  manner  in  which  the  figure  of  8 
bandage  acts,  it  is  evident  that  the  former  can  never 
be  satisfactorily  fulfilled  by  the  latter.  Hence  we 
may  judge,  what  improvement  the  art  has  received 
from  the  iron  cross  of  Heister,  the  compress  of  Pe- 
tit, drawn  transversely  over  the  oblique  turns  of  the 
bandage,  the  waistcoat  which  Brasdor fastened  round 
the  thorax  of  his  patients,  and  the  leathern  apparatus, 
lately  proposed  by  a  German  practitioner.  These 
means,  though  diversified  in  their  form,  are  similar 
in  their  effect,  and,  being  nothing  but  modifications 
of  the  figure  of  8  bandage,  possess,  like  it,  the  radi- 
cal fault  of  not  offering  a  resistance  directly  opposed 

5 


26 

to  the  two- fold  power,  arising  from  the  muscular 
action  and  the  gravitation  of  the  shoulder. 

As  to  what  remains,  it  will  be  sufficient  to  show 
the  insufficiency  of  the  process  of  reduction  (22),  by 
means  of  the  knee  placed  between  the  shoulders,  in 
order  to  demonstrate  the  existence  of  a  like  insuffi- 
ciency in  all  those  forms  of  apparatus,  which,  as 
Brasdor  remarks,  have  for  their  object  a  continuance, 
during  the  treatment,  of  the  effect  produced  by  that 
process. 

31.  On  the  other  hand,  those  indications  will  be 
fulfilled  v/ith  exactness,  by  such  a  form  of  apparatus 
as  will  render  permanent  the  action  of  the  means  of 
reduction  which  were  employed  by  Paul  of  Egina, 
by  certain  Arabian  physicians,  and  by  Pare;  w^hich 
have  been  renewed  by  Desault,  and  tend  to  draw 
the  shoulder  upward,  backward,  and  outwai^d  (23 
and  24). 

Pecceti  appears,  in  the  last  century,  to  have  had 
a  faint  view  of  the  proper  indication  on  this  subject, 
when,  under  the  article  of  fractures,  he  advises  the 
bail  to  be  suffered  to  remain  under  the  anii  during 
the  treatment  of  the  injury.  But  the  figure  of  8  ban- 
dage, united  to  this  expedient,  counterbalances  its 
effect,  rendering  it  of  no  avail,  and  Pecceti  was 
therefore  no  more  successful  than  others,  in  obtain- 
ing a  cure  of  the  fracture,  unaccompanied  by  de- 
formity. 

32.  An  overlapping  m.ore  or  less  perceptible 
never  failed  to  accompany  the  consolidation  or  knit- 
ting of  the  bone,  and  here,  as  in  many  other  cases, 
practitioners  laboured  to  explain  what  they  knew  not 


27 

how  to  prevent.  The  impracticability  of  surround- 
ing the  part,  as  in  other  fractures,  with  a  circu- 
lar bandage,  appeared  to  Heister,  Petit,  and  Duver- 
ney,  to  be  the  cause  of  this  deformity.  They  sup- 
posed that  to  be  a  superabundant  callus,  which  was 
nothing  but  a  displacement  of  the  fragments.  These 
visionary  hypotheses  ceased  to  exist,  as  soon  as  this 
displacement  was  prevented  by  a  proper  apparatus. 

Desault  sought  for  this  form  of  apparatus,  as  well 
as  for  his  other  bandages,  in  the  multiplied  applica- 
tion of  means  already  known,  without  inventing 
new  ones.  Bandages  and  compresses,  easy  to  be 
procured,  and  already  rendered  familiar  to  surgeons 
by  daily  use,  served  him  for  the  construction  of  his 
apparatus,  for  which  several  machines  had  been  al- 
ready proposed* 

33.  The  pieces  of  which  this  apparatus  is  com- 
posed, are, 

1st,  Thi-ee  rollers,  three  inches  broad;  the  two 
first,  six,  and  the  other  ^ight,  ells  long,  each  one 
rolled  up  separately. 

2dly.  A  bolster  or  pad  (a,  b.  Fig,  1),  made  in  the 
form  of  a  wedge,  out  of  pieces  of  old  linen.    Its " 
length  should  be  equal  to  that  of  the  humerus,   its 
breadth  four  or  five  inches,  and  its  thickness  at  the 
base  (a),  about  thi^ee  inches, 

3dly,  Two  or  three  long  compresses. 

4thly.  A  small  sling  for  the  ai^m,  (Fig.  5), 

5thly,  A  piece  of  linen  large  enough  to  cover  the 
whole  bandage. 

Every  thing  being  properly  arranged,  the  follow- 
ing is  the  mode  of  applying  the  apparatus,  which  of 
itself  reduces  the  fracture. 


28 

34.  The  patient  being  placed  in  a  standing  posi- 
tion, or,  if  his  case  render  that  impracticable,  on  a 
seat  without  a  back,  an  assistant  elevates  the  arm  of 
the  affected  side,  and  supports  it  at  nearly  a  right 
angle  with  the  body  (Fig.  2),  while  the  surgeon 
places  under  the  arm-pit  the  head  of  the  bolster, 
which  descends  along  the  side  of  the  thorax,  and 
w^hich  another  assistant,  situated  at  the  patient's 
sound  side,  holds  by  the  two  upper  corners. 

35.  The  surgeon  now  takes  one  of  the  first  roll- 
ers, applies  the  end  of  it  on  the  middle  of  the  bolster, 
fixes  it  there  by  two  circular  turns  round  the  body, 
and  passes  a  turn  obliquely  (a  a)  along  the  fore  part 
of  the  thorax,  ascending  to  the  sound  shoulder:  the 
roller  then  descends  behind,  passes  under  the  arm, 
and  returning  in  front  of  the  thorax,  makes  a  circu- 
lar turn  and  a  half,  horizontally.  Having  reached 
the  hind  part  of  the  thorax,  it  reascends  obliquely  by 
the  cast  (b),  as  it  had  done  before,  and  passes  over, 
before,  and  under,  the  sound  shoulder ;  having  thus 
crossed  the  turn  (a  a),  the  roller  again  passes  across 
the  hind  part  of  the  thorax,  and  finishes  by  circular 
turns,  which  completely  cover  the  bolster.  A  pin  is 
now  to  be  fixed  in  the  place  of  crossing  of  the  roller 
on  the  sound  shoulder,  to  prevent  the  turn  (a)  fi-om 
slipping  downward. 

The  application  of  this  first  roller  is  intended  for 
no  other  purpose,  than  firmly  to  fix  the  bolster  which 
is  held  up  by  the  tvvo  oblique  turns  before  and  be- 
hind, and  secured  against  the  body,  by  the  subse- 
quent circular  turns. 

36.  The  bolster  being  fixed,  the  surgeon  apply- 
ing one  hand  to  its  external  surface,  pushes  it  up- 


29 

wards,  and,  with  the  other,  taking  hold  of  the  elbow, 
after  having  half-bent  the  fore  arm,  lowers  the  arm, 
till  it  is  laid  along  the  bolster.  He  then  presses  its 
lower  extremity  forcibly  against  the  side  of  the  tho- 
rax, pushing  it  upwards  at  the  same  time,  and  direct- 
ing its  upper  extremity  a  little  backwards. 

The  application  of  the  bandage  constitutes  a  part 
of  the  process  of  reduction.  The  humerus,  now  con- 
verted into  a  lever  of  the  first  kind,  is  di'awn  at  its 
upper  end  from  the  shoulder,  in  proportion  as  its 
lower  end,  is  approximated  to  the  thorax  ►  The 
scapulary  fi-agment  being  drawn  along  with  it,  and 
directed  at  the  same  time  upward  and  backwai'd, 
comes  into  contact  with  the  sternal  fragment,  and  in 
an  instant  the  deformity  of  the  part  disappeai's. 

37.  The  arm  being  thus  situated,  is  given  in 
charge  to  an  assistant,  who  retains  it  in  the  same  po'- 
sition  in  which  he  received  it  from  the  surgeon,  by 
pressing  on  it  with  one  hand,  and  with  the  other 
supporting  the  fore  arm  half  bent,  and  placed  hori- 
zontally across  the  breast. 

The  second  roller  is  next  to  be  applied.  The 
end  of  this  is  carried  under  the  arm-pit  of  the  sound 
side.  It  is  then  brought  across  the  breast,  over  the 
superior  part  of  the  diseased  arm,  and  extends  across 
the  thorax  behind  till  it  passes  under  the  arm-pit„ 
Two  circular  turns  cover  the  first.  The  roller  must 
then  ascend  to  the  lower  part  of  the  shoulder,  by 
oblique  turns  (c.  c.  Fig.  3),  each  of  v/hich  must  be^ 
overlapped  by  the  succeeding  one,  to  the  extent  of 
about  the  third  part  of  its  breadth.  It  is  necessary 
that  these  turns  be  applied  in  such  a  way,,  as  to  bind 


30 

but  very  gently  above,  and  to  increase  in  tightness, 
as  they  descend  neai'er  to  the  lower  extremity  of  the 
humerus. 

The  use  of  this  second  roller  is,  to  supply  the 
place  of  the  hand  of  the  assistant,  in  pressing  the 
ai'm  against  the  side  of  the  thorax ;  its  effect  evidently 
is  to  draw  the  upper  extremity  of  the  arm  outw^ards, 
and,  as  it  is  already  directed  backwards,  to  retain  it 
in  that  position.  The  compression  of  the  circular 
turns  on  the  arm,  being  thus  gradually  augmented, 
becomes,  on  the  one  hand,  more  efficacious,  because 
it  acts  on  a  greater  surface,  and  on  the  other,  less  trou- 
blesome, because,  being  more  divided,  it  is  less  felt 
at  the  lower  exti'emity  of  the  arm,  where  it  bears 
with  most  force. 

38.  A  third  indication  remains  still  to  be  fulfilled, 
namely,  to  retain  the  shoulder  in  its  elevated  position, 
and,  by  that  means,  to  assist  in  the  extension  of  the 
fragments,  which  already  has  some  effect  in  prevent- 
ing a  depression. 

To  fulfil  this  indication,  an  assistant  sustains  the 
elbow  in  its  elevated  position,  with  one  hand,  and, 
with  the  other,  supports  the  patient's  hand  before  his 
tareast,  while  the  surgeon  fills  with  lint  the  hollow 
spaces  around  the  clavicle.  He  then  applies  on  the  cla- 
vicle, at  the  place  where  it  is  fractured,  the  two  long 
compresses,  wet  vv'ith  vegeto-mineral  water,  or  some 
other  cooling  liquid.  Taking  novf  the  last  roller,  he 
fixes  the  end  of  it  under  the  sound  shoulder;  from 
thence  he  brings  it  obliquely  across  the  breast,  over 
the  long  compresses^  and  carries  it  down  behind  the 
shoulder  along  the  posterior  part  of  the  arm,  till  it 


•passes  under  the  elbow.  From  this  point,  he  again 
carries  it  obliquely  upwards  across  the  breast  to  the 
arm-pit,  then  across  the  back,  over  the  compresses, 
and  brings  it  down  again  before  the  shoulder,  along 
the  front  of  the  humerus  till  it  again  reaches  the  el- 
bow. From  thence  the  roller  again  ascends  oblique- 
ly behind  the  thorax,  passing  under  the  arm-pit, 
where  the  first  cast  of  the  roller  is  covered,  and  from 
whence  it  again  starts,  to  run  the  same  course  we 
have  just  described.  This  constitutes  a  second 
round,  which  covers  in  pait  the  first,  and  forms  a 
kind  of  double  triangle  (e,  f,  d),  situated  before  the 
breast,  and  over  the  circular  turns  of  the  other  rollers 
(c.  c.  Fig.  4).  The  remaining  part  of  the  roller, 
brought  from  behind  forward,  is  employed  in  circular 
turns  over  the  arm,  and  round  the  thorax,  for  the 
purpose  of  preventing  the  displacement  of  the  first 
part.  To  make  it  the  more  secure,  it  is  fastened  with 
pins  at  its  different  places  of  crossing. 

The  sling  (Fig.  4)  is  next  passed  under  the  hand, 
and  fastened  above  to  the  ascending  turns  (d),  and 
not  to  the  circular  (c  c),  which  the  weight  of  the 
hand  would  be  likely  to  draw  downward. 

39.  It  is  only  necessary  to  examine  the  course  of 
this  third  roller,  to  see,  that,  united  to  the  sling,  it  is 
well  calculated  to  support  the  external  fragment, 
which  the  weight  of  the  shoulder  has  a  tendency  to 
depress,  on  a  level  with  the  internal  one.  It  supplies 
the  place  of  the  assistant,  who  raises  the  elbow  and 
supports  the  hand  of  the  patient,  in  like  manner  as 
the  second  roller  performs  the  office  of  the  assistant, 
who  presses  the  lower  part  of  the  humerus  against 
the  side  of  the  thorax. 


32 

On  the  other  hand,  the  circular  turns,  by  which 
the  apphcation  of  the  third  roller  is  finished,  being 
du'ected  from  before  backward,  push  in  the  same 
direction  the  arm  and  shoulder,  wiiich  have  been 
already  carried  that  way,  by  the  process  of  reduction, 
and  thus  retain  them  in  their  proper  places. 

Hence  may  be  infened  the  truth  of  the  proposi- 
tion, which  we  have  been  endeavouring  to  demon- 
strate; namely,  that  the  bandage  of  Desault,  con- 
structed according  to  the  general  principle  formerly 
established  (20),  for  fractures  of  the  body  of  the  cla- 
vicle, is  calculated  to  retain  the  external  extremity 
of  the  humeral  fragment  upw^ard,  outward,  and  back- 
ward, 

40.  The  casts  of  the  rollers,  thus  surrounding  the 
thorax,  however  v/ell  they  may  be  secured,  are  yet 
liable  to  be  displaced,  particularly  when  the  patient 
is  ini)ed.  This  inconvenience  may  be  avoided,  by 
suiTounding  the  whole  with  a  piece  of  linen,  leaving 
nothing  uncovered,  but  the  sound  arm,  which  is  at 
liberty  to  perform  its  usual  motions. 

The  arm  of  the  diseased  side,  being  thus  fixed  in 
such  a  manner,  as  to  constitute  a  whole  or  entire 
body  with  the  thorax,  follows  its  movements,  with- 
out producing  any  displacement.  It  is  thus,  that  by 
the  apparatus  for  a  continued  extension  of  the  thigh, 
the  fragments  of  the  os  femoris,  forming  an  immove- 
able whole  w^ith  the  pelvis,  cannot  change  their  situ- 
ation, even  in  following  the  motions  of  the  trunk. 

Hence  arises,  in  fractures  of  the  clavicle,  this  ad- 
vantage, that  the  patient  is  not  obliged  to  keep  his 
bed,  but  is  able  even  to  attend  to  his  business,  during 
ihQ  progress  of  the  cure. 
\ 


53 

41.  I  will  not  dwell  on  the  numerous  objections 
urged  by  different  authors  against  the  bandage  which 
has  just  been  described.  What  answer,  indeed,  can 
be  given  to  those  winters,  who  fancy  that  they  behold 
the  patient  in  the  greatest  danger  of  immediate  suffo- 
cation; who  dread  an  approaching  mortification  of 
the  arm  of  the  diseased  side;  who  allege,  contrary 
to  the  rules  of  the  art,  that  there  is  no  impression 
made  immediately  on  the  clavicle,  but  on  a  neigh- 
bouring bone ;  who,  &c.  &c.  ?  Twenty  times  in  a 
year,  has  experience  ansv/ered  those  objections,  in 
the  Hotel-Dieu ;  and  there  is  not  a  pupil  of  Desault, 
who  has  not,  as  well  in  this,  as  in  many  other  cases, 
seen  that  objections,  plausible,  indeed,  when  consi- 
dered in  the  closet,  or  at  a  distance  from  a  sick  room, 
dwindle  to  nothing  at  the  bed-side  of  the  patient. 

42.  In  those  cases  (which,  as  Hippocrates  remarks, 
very  rarely  occur)  where  the  external  fragment  pro- 
jects over  the  internal  one  (12),  the  bandage  must 
be  somewhat  varied,  although  the  two  principal  indi- 
cations, of  drawing  the  shoulder  backward  and  out- 
ward, must  still,  as  in  other  cases,  be  fulfilled.  The 
only  additional  circumstance,  therefore,  necessary  to 
be  attended  to  here,  is,  not  to  elevate  the  shoulder,  by 
pushing  it  upwards.  This  may  be  easily  avoided, 
1st,  by  omitting  to  raise  the  elbow,  when  applying 
the  bandage ;  2dly ,  by  drawing  the  third  roller  a  little 
tighter  than  usual.* 

*  This  paragraph  is  so  obscure  in  the  original,  that  a  trans- 
lation of  it  would  be  scarcely  intelligible.  Instead  of  a  mere 
translation,  therefore,  I  have  given  rather  a  comment  on  what 
I  believe  to  be  its  true  meaning.  Traxs. 


34 

The  fragments,  being  reduced  to  the  same  level, 
and  brought  into  apposition,  by  this  two-fold  atten^ 
tion,  will  unite  as  in  ordinary  cases. 

If  the  fracture  exist  at  the  end  of  the  clavicle  next 
to  the  humems,  the  difficulty  of  their  being  displaced 
renders  the  application  of  the  bandage  less  necessary. 
Prudence,  however,  demands  that  it  be  not  altogether 
neglected. 

§  VIII. 

6f  tee  treatment  during  the  formation 
of  the  callus. 

The  regimen  to  be  pursued  during  the  reunion  of 
the  clavicle,  varies  according  to  circumstances.  It  is 
impracticable  to  lay  down  general  rules,  applicable  to 
all  affections  of  this  kind.  Here,  however,  much 
more  than  in  other  cases,  if  the  division  of  the  bone  be 
simple,  and  no  imfortunate  accident  occur,  it  is  al- 
ways unnecessai-y  to  resti^ain  the  patient  from  his 
usual  course  of  life,  beyond  the  second  or  third  day. 
But,  though  internal  means  are  for  the  most  part 
omitted  in  the  treatment,  the  apparatus  is  a  subject  on 
which  too  much  attention  cannot  be  bestowed.  With 
whatever  degree  of  exactness  it  may  be  at  first  ap- 
plied, it  will  soon  become  loose,  and  oppose  a  dimi- 
nished resistance  to  the  v/eight  of  the  shoulder,  and 
the  action  of  the  muscles.  Hence,  unless  it  be  fre- 
quently examined,  the  fragments  will  be  displaced. 
The  following  case  furnishes  a  detail  of  the  treatment 
subsequent  to  the  reduction,  to  which,  in  ordinary 
cases,  Desault  had  recourse. 


55 

Case  III.  Mary  Adel,  aged  thirty,  as  she  was 
crossing  a  path  covered  with  ice,  in  the  severe  win- 
ter of  1788,  fell  on  the  point  of  her  left  shoulder,  and 
fractured  the  clavicle  about  the  middle.  Being 
brought  to  the  Hotel-Dieu  a  few  hours  after  the  acci- 
dent, she  was  dressed  in  the  manner  just  described, 
and,  as  the  fracture  was  sinaple,  it  was  judged  suffi- 
cient to  make  a  slight  diminution  in  the  quantity  of 
her  aliment,  during  the  two  or  three  first  days.  The 
dressing  was  moistened  every  morning,  with  vegeto- 
mineral  water,  at  the  place  corresponding  to  the  frac- 
ture. 

On  the  fourth  day  the  piece  of  linen  that  surroun- 
ded the  bandage  was  removed,  for  the  purpose  of 
examining  the  state  of  the  parts.  Every  thing  was 
found  in  its  proper  situation,  and  the  covering  was 
replaced  till  the  seventh  day,  when  the  rollers  appear- 
ed to  be  somewhat  relaxed.  The  apparatus  was 
taken  off,  and  reapplied  as  at  first,  the  compresses 
being  carefully  moistened  with  vegeto-mineral  water, 
at  the  part  lying  over  the  fracture.  After  the  third 
day  the  patient  was  permitted  to  return  to  her  usual 
regimen.  The  third  roller  being  a  little  deranged 
on  tlie  tenth  day,  it  was  taken  off,  and  reapplied  as 
at  first,  together  with  the  sling.  The  fragments  were 
examined  and  found  in  pei'fect  contact.  The  patient 
was  up  during  the  whole  day,  walked  about  the 
house,  and  experienced  no  other  inconvenience  than 
that  of  not  being  able  to  use  the  left  arm. 

On  the  thirteenth  day,  the  bandage  was  again  re- 
applied, and  allowed  to  remain  till  the  sixteenth,  when 
the  patient  having  disturbed  it,  it  was  once  more 


36 

changed.  At  this  period,  the  fi-agments,  already  firm- 
ly united,  exhibited  scai'cely  a  vestige  of  the  division 
they  had  sustained. 

The  reunion  was  complete  by  the  twentieth  day, 
when  ail  the  pieces  of  apparatus  were  dispensed  with, 
except  the  bolster  and  the  &ccuud  luUer,  which  were 
also  removed  two  days  afterwards,  as  tliey  were  found 
to  be  no  longer  necessary. 

The  continued  inactivity  of  the  limb,  during  the 
treatment,  had  occasioned  a  stiffness  in  the  shoulder. 
This  was  gradually  done  away  by  making  the  patient 
move  her  arm  in  all  dii'ections,  twice  a  day,  each 
time,  for  the  space  of  an  hour. 

On  the  twenty-ninth  day  she  left  the  hospital, 
carrying  v/ith  her  nothing  to  remind  her  of  the  injury 
she  had  sustained.  She  was  free  from  that  uneasiness 
which  is  the  consequence  of  a  tedious  and  ill-mana- 
ged treatment,  during  which  the  exercise  of  the  limb 
,  has  be^  neglected. 

§  IX. 

OF    COMPLICATIONS. 

..  44.  We  are  in  possession  of  but  few  observations 
particularly  relative  to  the  different  complications, 
that  may  accompany  fi^actures  of  the  clavicle.  The 
treatment,  in  such  cases,  varied  according  to  circum- 
stances, must  be  accommodated  to  the  mdications 
common  to  all  fractures  of  this  kind. 

When  splinters,  displaced  in  different  directions, 
whether  adhering  to  the  bone  or  not,  irritate  the  soft 
parts,  and,  having  passed  through  the  integuments, 


37 

appear  without,  most  practitioners  advise  to  remove 
them  and  cut  ofF  such  parts  as  project  beyond  the 
fractured  end  of  the  bone,  previously  to  reduction. 
This  direction  is  founded  on  the  severe  pains  which, 
in  such  cases,  accompany  the  common  treatment  of 
the  injury,  and  which  the  figure  of  8  bandage  always 
augments,  by  drawing  the  shoulder  inward,  and  con- 
sequently pressing  the  soft  parts  against  the  project- 
ing parts  of  the  fi^agment,  or  the  points  of  the  splinters. 
But  if  the  splinters,  adhering  as  yet  to  each  other  and  to 
the  bone,  by  means  of  tlie  periosteum,  have  not  assum- 
ed the  nature  of  foreign  bodies,  (that  is,  if  they  be  not 
actually  dead)  it  is  always  proper  to  replace  them.  It 
is  here  only  that  we  meet  wdth  an  occasion  for  that 
part  of  the  process,  of  reduction  denominated  con- 
formation,^- which  is  never  requisite  in  other  cases. 

A  fragment  which  has  penetrated  the  soft  parts, 
but  has  not  been  long  exposed  to  the  air,  disappears, 
and  is  replaced  by  extension,  provided  it  be  properly 
directed.  Being  retained  afterwards  in  a  state  of  con- 
stant extension,  it  can  neither  be  displaced,  nor  cause 
pain  by  irritating  the  parts,  which  is  the  inevitable 
result  of  the  figure  of  8  bandage. 

*  That  process  or  operation  in  which  the  surgeon  uses  his 
hands  to  effect  the  reduction  and  apposition  of  parts,  which 
cannot  be  accomplished  by  extension  and  counter-extension 
alone.  If  a  bone  be  broken  into  two  or  three  pieces,  mere 
extension  and  counter-extension  will  not  bring  all  the  frag^ 
ments  into  their  proper  places,  so  as  to  restore  the  natural 
form  of  the  part.  In  such  cases,  the  surgeon  uses  his  hands  to 
aid  the  action  of  the  extended  muscles,  and  this  is  the  process 
which  our  author  denominates  conformation.  The  term  occurs 
in  many  places  in  the  course  of  the  work.  Trans., 


In  cases  of  tliit^  kind,  it  is  useful  to  protect  the 
shoulder  with  a  small  splint,  which  may  support  the 
turns  of  the  bandage,  and  prevent  their  pressure  on 
the  splinters,  or  the  broken  ends,  which  they  might 
otherwise  disturb.  These  precautions  are  alike  indis- 
pensable when  the  fracture  is  double. 

Case  IV.  Francis  Ricord,  twenty ^five  years  of 
age,  was  received  in  the  month  of  July,  1790,  into  the 
Hotel-Dieu  of  Paris.  On  the  preceding  day,  a  piece 
of  timber  having  fallen  from  a  considerable  height  on 
his  right  shoulder,  had  broken  the  clavicle  of  that 
side  into  several  pieces.  Severe  pains,  which  occur- 
red at  the  moment  of  the  accident,  had  continued 
throughout  the  night,  and  were  still  sensibly  felt.  The 
slightest  motion  of  the  part  augmented  them  to  such 
a  degree,  as  to  extort  from  the  patient  piercing  cries. 

The  point  of  the  shoulder  being  very  much  de- 
pressed, was  also  drawn  perceptibly  forward  and  in- 
ward; and  a  large  echymosis,  without  any  external 
wound,  occupied  its  whole  extent. 

Desault  being  satisfied  that  the  several  fragments 
were  all  connected  together,  and  that  none  of  them 
was  separated  from  the  periosteum,  placed,  as  in  or- 
dinary cases,  the  bolster  under  the  arm,  completed 
the  reduction,  and  applied  a  splint  along  the  course 
of  the  clavicle,  after  having,  with  his  hands,  brought 
the  fractured  pieces  into  contact.  Confident,  then, 
that  the  form  of  the  part  was  perfectly  restored,  he 
applied  the  bandage,  which  was  moistened  with 
vegeto-mineral  water,  twice  or  thi'ice  a  day. 

At  the  moment  of  reduction  the  pains  ceased,  and 
were  felt  no  more  till  the  fifth  day,  when  the  bandage 


39 

being  a  little  relaxed,  admitted  of  a  slight  displace- 
ment of  the  fragments.  This  displacement  was  remo- 
ved, and  the  pains  along  with  it,  by  the  reapplication 
of  the  apparatus. 

During  the  six  first  days  a  very  strict  diet  was 
enjoined.  This,  however,  was  dispensed  with  by 
degrees,  till,  on  the  thirteenth  day,  the  patient  re- 
turned to  his  usual  regimen.  On  the  seventeenth 
day,  there  remained  nothing  of  the  echymosis,  but  a 
yellow  tinge,  the  customary  consequence,  of  such  an 
accident.  The  precautions  inculcated  in  the  preced- 
ing case,  were  employed  also  in  this,  and  the  patient 
was  discharged  perfectly  cured,  on  the  forty-second 
day  from  the  time  of  his  admission.  Nor  had  he 
experienced,  during  his  treatment,  those  severe  and 
long  continued  pains,  which,  under  a  different  ma- 
nagement, so  frequently  accompany  this  kind  of  frac- 
tui'e. 

EXPLANATION   OP   THE  FIRST  PLATE. 

Fig.  1.  A  bolster  made  in  the  form  of  a  wedge,  in- 
tended  to  be  placed  between  the  arm  and  the  side 
of  the  thorax. 

a.  Its  base,  which  should  fif  the  hollow  of  the  arm-pit. 

b.  Its  summit  reversed,  against  which  the  elbow  is  to 

be  applied. 
Fig.  2.  The  first  roller  applied  for  the  purpose  of 

fixing  the  bolster  against  the  side  of  the  thorax. 
a  a.  Oblique  casts  before,  passing  over  the  opposite 

shoulder,  in  order  to  hold  it  up. 
b.  Oblique  casts  from  behind,  crossing  the  first  ones 

on  the  shoulder. 


40 

d  d.  Circular  casts  round  the  trunk,  covering  the  bol- 
ster, which  they  fix  laterally. 
Fig.  3.  The  second  roller,  applied  to  fix  tlie  arm 

against  the  bolster. 
a^  b.  Portions  of  the  oblique  casts  of  the  first  roller, 

left  uncovered  by  this  one. 
c  c.  Turns  of  the  second  roller,  covering  those  of  the 
first,  loose  above,  and  tighter  beioAv,  for  the  pur- 
pose of  dj'awing  the  superior  extremity  of  the 
humerus  outwards. 
d.  Their  passage  over  the  side  opposite  to  the  bolster. 
Fig.  4.  The  third  roller  intended  to  keep  the  point  of 

the  shoulder  raised. 
a  a^b.   Oblique  casts  of  the  first  roller,  remaining 

uncovered. 
c  c.  Turns  of  the  second,  seen  through  the  opening 

of  those  of  the  third. 
d.   Oblique  casts  of  the  tliird,  ascending  fi-om  the  arm- 
pit over  the  shoulder  of  the  diseased  side,  to  de- 
scend again  behind,  along  the  arm,  and  pass  under 
the  elbow. 
f  k.  A  continuation  of  the  preceding  casts,  reascend- 
ing  under  the  sound  ami-pit,   and  from  thence 
behind  the  thorax,  over  the  diseased  shoulder. 
c.  A  continuation  of  the  same  casts,  descending  on 
the  fore  side  of  the  arm,  passing  under  the  elbow, 
and  ascending  again  under  tlie  aim-pit  of  the 
sound  side. 
g.  The  remainder  of  the  roller,  intended  to  be  em- 
ployed in  circular  turns,  in  order  to  secure  the 
casts  (f ,  and  prevent  them  from  slipping  outward. 
Fig*.  5.  A  sling  vv^hich  should  be  fastened  to  the  ob- 
lique cast  d  (Fig.  4),  to  support  the  hand. 


//.  t 


jSnifravi  by'W.Knr.afs. 


41 
MEMOIR  III. 

ON   THE   LUXATION   OF   THE    CLAVICLE, 

1.  The  clavicle,  which  forms  a  moveable  abut- 
ment for  the  shoulder,  and  receives  and  sets  bounds  to 
most  of  the  movements  of  that  part,  and  of  the  arm, 
exhibits  at  its  extremities,  two  articulations,  essen- 
tially different  from  each  other  in  their  form,  dispo- 
sitions, and  uses.  These  differences  give  rise  to  dif- 
ferences equally  essential  with  regard  to  the  disloca- 
tions to  which  they  are  subject. 

2.  On  the  sternal  extremity,  a  small  surface,  con- 
vex from  above  downwai'ds,  and  concave  fi'om  before 
backwards,  is  fitted,  by  means  of  an  intervening  car- 
tilage, to  a  much  smaller  surface  of  the  sternum, 
concave  and  convex  in  opposite  directions. 

One  capsule,  two  ligaments,  viz.  the  interclavi- 
cular and  costo- clavicular  ligaments,*  and  the  ante- 
rior portion  of  the  sterno-cleido-mastoideus  muscle, 
sti'engthen  the  connexion  of  these  two  surfaces,  and 
tend,  on  one  hand,  to  prevent  their  luxation,  while, 
on  the  other,  this  luxation  is  favoured  and  facilitated 
by  the  following  circumstances :  1st,  the  dispropor- 
tion between  the  dimensions  of  the  two  articulating 

*  I  find  in  English  books  of  anatomy  no  appi'opriate  names 
for  these  two  ligaments.  I  am  therefore  obliged  to  translate 
the  French  terms  for  them  literally.  The  anatomist  will  have 
no  difficulty  in,  recollecting  their  situation.  Trans. 

7 


42 

surfaces;  2dly,  the  mobility  of  the  joint;  and  Sdly, 
by  this  j  oint's  constituting  a  kind  of  centre  for  the 
motions  of  the  arm. 

3.  On  the  humeral  side,  an  elliptical  surface, 
slightly  convex,  and  inchned  downwards,  is  imme- 
diately joined  to  a  corresponding  surface  of  the  acro- 
mion, elliptical  also,  a  little  concave  and  directed 
upwards.  Hence  two  kinds  of  inclined  plains,  which 
would  be  very  liable  to  dislocations,  by  sliding  easily 
over  each  other,  were  they  not  firmly  secured  by  a 
capsule,  by  accessory  fibres,  by  the  intersection  of 
those  of  the  deltoid  and  trapezius  muscles,  and, 
above  all,  by  two  ligaments,  the  rhomboid  and  the 
conoid.* 

Having  laid  down  these  preliminary  considera- 
tions, let  us  proceed  to  examine,  in  particular,  each 
kind  of  luxation  to  which  the  clavicle  is  subject. 

LUXATION  OF  THE  STERNAL  EXTRE- 
MITY. 


II. 


OF    THE    CAUSES    AND    DIFFERENT    KINDS    OF 
DISPLACEMENT. 

4.  The  sternal  articulation  of  the  clavicle  expe- 
riences different  changes,  according  to  the  different 
movements  of  this  bone.  If  these  movements  be  in 
a  backward  direction,   the   articulating  surface   is 

*  I  do  not  recollect  any  terms  in  English  works  of  ana- 
tomy equivalent  to  these,  Tran^ 


43 

turned  forward,  straining  the  anterior  part  of  the  cap- 
sule, the  corresponding  ligament,  and  the  extremity 
of  the  stemo-cleido-mastoideus  muscle.  If,  on  the 
other  hand,  they  be  in  a  forward  direction,  the  poste- 
rior ligament,  and  the  adjacent  portion  of  the  capsule 
are  overstretched.  In  motions  directed  upwai^ds,  the 
costo- clavicular  ligament,  and  the  external  and  infe- 
rior part  of  the  capsule,  and  in  those  directed  down- 
wards, the  inter- clavicular  ligament,  and  the  internal 
portion  of  the  capsule,  experience  a  similar  degree  of 
tension. 

5.  Hence  it  follows,  1st.  That  the  natural  move- 
ments of  the  shoulder  may  be  regarded  as  predispo- 
sing causes  of  luxation,  because  at  the  part  where 
tension  is  excessive,  the  ligaments  are  disposed  to 
give  way,  and  suffer  the  sternal  extremity  to  escape  : 
2dly.  That  the  efficient  causes  will  be,  all  external 
forces  acting  on  the  clavicle  in  such  a  way  as  to  in- 
crease its  motions  beyond  their  natural  degree,  and 
beyond  the  resistance  which  the  ligaments  are  capa- 
ble of  making.  Thus  a  fall  on  the  point  of  the  shoul- 
der, forcing  it  suddenly  backward  and  inward,  pro- 
duces a  luxation  forward.  But,  in  general,  as  the 
strength  of  the  articular  ligaments  is  superior  to  the 
resistance  of  the  clavicle  itself,  a  fracture  takes  place 
more  frequently  than  a  luxation,  in  the  proportion  of 
nearly  six  to  one. 

Though  falls  on  the  point  of  the  shoulder  are  of- 
tentimes productive  of  luxation  of  the  clavicle,  they 
are  not  the  exclusive  causes  of  that  accident.  De- 
sault  has  seen  the  sternal  extremity  forced  from 
its  cavity  by  the  knee  being  pushed  violently  against 


44 

the  middle  of  the  back,  while  the  shoulders  Were 
dra^vn  at  the  same  time  backwards. 

Case  I.  A  porter  dislocated  his  clavicle  in  the 
following  manner.  He  was  carrying  a  very  heavy  bur- 
den, suspended  from  his  shoulders  by  cords  that, 
passed  under  each  arm-pit.  Being  desirous  of  resting 
himself  by  the  way,  he  placed  on  a  block  the  burden 
he  carried,  which  slipping  backward,  drew  his  shoul- . 
ders  in  the  same  direction,  and  at  the  instant  of  his 
attempting  to  retain  it  and  prevent  it  from  falling, 
produced  a  luxation  of  the  clavicle. 

7.  It  follows  from  what  has  been  said  respecting 
the  different  states  of  the  articulation,  during  its  vari- 
ous motions  (4),  that  the  clavicle  is  not  equally  liable 
to  be  luxated  in  every  direction.  Inclining  naturally 
backward,  but  a  very  slight  degree  of  motion  in  that 
direction  is  necessaiy,  to  effect  a  luxation  forward. 
To  produce  a  luxation  backward  or  inward,  it  is  ne- 
cessary, on  the  other  hand,  that  the  humeral  extre- 
mity of  the  bone  should  make  a  sweep  at  least  three 
times  the  extent  of  that  requu'ed  in  the  preceding 
case.  Besides,  motions  in  this  direction  are  accompa- 
nied with  pain,  particularly  if  they  be  made  by  force. 
Luxation  downwai^d  is  prevented,  on  the  one  hand, 
by  the  cartilage  of  the  first  rib,  which  presents  to  the 
bone  an  insurmountable  barrier.  On  the  other  hand, 
to  produce  this  kind  of  luxation,  it  would  be  neces- 
sary for  the  external  extremity  of  the  clavicle  to  be 
forced  upwards,  an  occurrence  very  seldom  occa- 
sioned by  falls.  Luxation  upward,  or  over  the  supe- 
rior edge  of  the  sternum,  must  be  the  effect  of  a 
stroke,  which,  by  depressing  the  point  of  the  shoul- 


45 

der,  and  forcing  it  at  the  same  time  forward,  presses 
the  sternal  extremity  against  the  internal  and  superior 
part  of  the  capsule,  which,  being  thus  lacerated,  suf- 
fers a  luxation  to  take  place.  But  such  a  derangement 
of  the  articulating  surfaces  is  very  rarely  produced 
by  falls.  Whence  it  follows,  that  of  the  different  kinds 
of  luxation  of  the  clavicle,  that  in  a  downward  direc- 
tion is  altogether  impracticable.  Those  backward 
and  upward,  though  possible,  occur  but  rarely  in 
practice  ;  while  that  in  a  forwai'd  direction,  on  the 
contrary,  is  not  an  unfrequent  accident.  This  tends 
to  confirm  the  observations  of  practitioners,  and  par- , 
ticularly  of  Desault,  whose  immense  collection  on 
the  subject  furnishes  examples  of  the  last  kind  of 
luxation  only. 

8.  In  these  luxations,  there  is  for  the  most  part,  a 
rupture  of  the  capsular  ligament,  and  an  escape  of  the 
bone  through  the  opening.  But  sometimes  the  liga- 
ment is  only  preteniaturally  distended,  and  then  the 
luxation  is  incomplete. 

§111. 

OF  THE  SIGNS. 

9.  Bu T  whatever  may  be  the  causes  or  kind  of  the 
luxation,  its  diagnosis  is  always  easy.  If  it  be  forward, 
the  direction  of  the  stroke  which  the  shoulder  has 
received,  furnishes,  at  first,  some  ground  of  suspicion. 
The  accident  is  certainly  known  by  the  appearance  of 
a  hai'd  and  unnatural  protuberance  in  front  of  the  ster- 
num, and  behind  the  extremity  of  the  sterno-cleido- 
mastoideus  muscle,  by  the  existence  of  a  sensible  de- 


I 


46 

pression  or  hollow  at  the  joint,  and  by  the  situation  of 
the  shoulder,  which  is  pushed  further  backward,  and 
is  less  projecting  and  more  approximated  to  the  trunk, 
than  ill  its  natural  state.  Add  to  these,  a  difficulty  in- 
p'erforming  motions  in  a  forward  direction,  which, 
when  somewhat  forced,  reduce,  in  proportion  as  they 
areacGomplished,  the  size  of  the  protuberance  formed 
bly  the  displaced  end.  The  head  is  always  inclined 
towards  the  side  where  the  luxation  exists;  an  atti- 
tude which  relieves  the  painful  drawing  or  tension 
produced  in  the  sterno-mastoideus  muscle,  by  the 
humeral   extremity  pushing  it  forward. 

10.  A  protuberance  over  the  superior  edge  of  the 
sternum,  a  difficulty  in  raising  the  shoulder,  the  pain 
which  results  from  attempting  such  a  motion,  the  di- 
minution of  the  protuberance  which  it  occasions,  the 
absence  of  the  sternal  extremity  from  its  natural  cavity, 
the  approximation  of  the  shoulder  to  the  thorax,  and 
its  depression  and  diminished  projection,  compared 
to  its  usual  state,  affi^rd  evidence  of  a  luxation  up- 
wards. 

11.  A  luxation  inward  or  backward,  would  be 
characterized  by  a  projection  of  the  shoulder  exterior- 
ly, by  a  difficulty  in  performing  motions  in  a  back- 
ward direction,  by  the  alarming  effects,  which,  as  Petit 
remarks,  the  compression  of  the  trachea  would  doubt- 
less produce,  and  by  a  depression  or  hollow  at  the 
joint,  more  perceptible  here  than  in  the  two  preceding 
cases. 

12.  These  appearances  will  be  more  or  less  stri- 
king, accordingly  as  the  membranes,  lacerated  or  only 
distended,  offer  a  greater  or  less  resistance. 


•     ■  §rv- 

OF  THE   REDUCTION. 

13.  To  reduce  a  luxation,  is,  in  general,  to  mak© 
the  bone  re-enter  its  cavity,  by  retracing,  or  retmiiing 
along,  the  same  route  which  it  followed  in  escaping 
from  it.  Now,  in  a  forward  luxation,  the  displace- 
ment is  from  behind  forward,  in  an  upward  one  from 
below  upward,  in  an  inward  or  backwaad  one  fron?. 
before  backwai'd,  but,  in  each  of  the  three,  it  is  more 
particularly  from  without  inward.  In  the  first  case, 
therefore  it  is  backward,  in  the  second,  forward,  in 
the  third  downward,  but,  in  each  of  the  three,  more 
particularly  outward,  that  the  powers  for  producing 
extension  must  be  directed. 

14.  Hence  the  method  generally  employed  by 
most  practitioners,  recommended  by  almost  every 
author  who  has  written  on  the  subject,  adopted  by 
Petit,  Duvemey,  Heister,  &c.  and  which  consists  in 
placing  the  knee  between  the  shoulders  of  the  patient, 
as  a  point  of  resistance,  by  the  aid  of  which  the  shoul- 
ders may  be  drawn  backward,  fulfils  only  half  of  the 
indication  of  cure ;  because  at  the  time  that  the  hu- 
meral extremity  is  drawn  backward,  it  is  not  directed 
sufficiently  outward. 

Hence  a  difficulty  of  replacing  the  bone  sometimes 
occurs,  a  difficulty  always  removed,  when,  pursuant 
to  the  method  employed  by  Desault  in  fractures  of 
the  clavicle  (see  Desault's  method),  the  arm  is 
made  to  serve  as  a  lever  of  the  first  kind,  to  carry 
backward  and  outward,  the  head  of  the  bone,  which 
is  displaced  in  the  opposite  directions,  when  the  lux^ 


48 

ation  is  forwai'd.  This  method  possesses  the  advan^ 
tage,  not  only  of  giving  the  powers  of  extension  a 
proper  direction,  but  also  of  increasing  them  to  a 
degree  even  beyond  what  is  necessary  for  effecting  a 
reduction,  by  removing  them  further  from  the  resist- 
ing force.  Hence  it  is  unnecessary  to  adopt  any  par- 
ticular measures  for  restoring  and  preserving  the  form 
of  the  part,  as  the  extension  is  alone  sufficient  for  that 
purpose. 

These  principles,  evidently  applicable  in  effecting 
a  reduction,  are  still  more  strikingly  so  in  the  means 
destined  for  retaining  it.  Let  us  apply  what  I  have 
just  said,  to  a  case  of  dislocation  in  a  forward  direc- 
tion. It  will  be  easy  to  transfer  it  afterwards  to  the 
other  kinds  of  luxation. 

§V. 

OF   THE    MEANS   OF   RETAINING   A   REDUCTION. 

15.  Few  luxations  are  so  speedily  reduced,  but 
few  are  more  easily  displaced  again,  than  that  of  the 
clavicle.  This  disposition  is  the  reverse  of  that  of 
most  other  luxations,  which  are  reduced  indeed  with 
difficulty,  but  seldom  afterwards  suffer  a  displace- 
ment. The  cause  of  this  we  find,  1st,  in  the  extreme 
mobility  of  the  clavicle,  to  which  all  the  motions  of 
the  arm  are  communicated;  2dly,  in  this  further  con- 
sideration, that  most  of  the  muscles,  which  have  their 
insertion  towards  the  shoulder,  tend  to  di'aw  this  bone 
inward,  when  the  ligaments,  in  consequence  of  being 
either  broken  or  distended,  as  happens  in  this  accident, 
do  not  offer  a  sufficient  rosistance. 


49 

16.  From  this  two-fold  cause  of  displacement, 
arises  a  two-fold  indication  in  the  arrangement  and 
application  of  the  apparatus.  These  are,  1st,  to  ren- 
der the  clavicle  immoveable,  by  restraining  every 
kind  of  motion  in  the  shoulder  and  arm;  2dly,  to 
retain  the  extremity  of  the  clavicle  outward,  a  direc- 
tion opposed  to  that  in  which  it  has  a  tendency  to  be 
displaced.  But  if  to  those  indications  we  compare 
the  forms  of  apparatus  hitherto  used,  we  will  readily 
perceive  that  they  are  insufficient  to  fulfil  them. 

17.  The  figure  of  8  bandage,  so  generally  in  use, 
and  all  the  various  modifications,  under  which  it  has 
been  revived,  without  being  improved,  fix  the  clavi- 
cle in  the  very  direction  most  favourable  to  a  dis- 
placement, and  even  do  it  in  the  very  maimer  in  which 
that  accident  is  sometimes  brought  about;  as  maybe 
seen  in  the  history  of  the  case  of  the  porter  (6).  This 
bandage  does  not,  under  any  of  its  modifications, 
prevent  the  motions  of  the  shoulder,  because  it  does 
not  restrain  those  of  the  arm,  which  remains  free  and 
unencumbered.  Far  from  constituting  an  antagonist 
power  to,  it  even  co-operates  with,  that  which  has 
produced  the  displacement.  ( For  further  light  on  this 
subject,  see  what  has  been  already  said  on  the  fracture? 
of  the  clavicle,  pages  22  and  25.) 

Bell,  in  condemning  the  figure  of  8  bandage,  not 
so  much  because  of  its  action  being  insufficient,  as 
because  of  its  obstructing  respiration,  proposes,  as  a 
substitute  for  it,  a  kind  of  machine  analogous  to  the 
iron  cross  of  Heister,  which,  being  fixed  by  straps 
passing  under  the  ai'm-pit,  and  round  the  neck  and 
body,  is  intended  to  retain  the  parts  firm  antl  immove- 


50 

able.  But  the  motions  of  the  arm  not  being  restrain- 
ed, nor  the  action  of  the  muscles  of  the  shoulder  op- 
posed by  an  antagonizing  power,  places  this  piece  of 
apparatus  in  the  same  class  with  those,  which,  from 
not  being  devised  and  constracted  on  a  proper  view 
and  conception  of  the  causes  of  displacement,  have 
no  affinity  to  rational  practice. 

18.  The  apparatus  for  a  continued  extension,  in- 
vented by  Desault,  for  fractures  of  the  clavicle,  fulfil 
here  all  those  indications  in  which  the  others  fail. 

By  this,  1st.  The  arm,  being  firmly  fixed  against 
the  side,  by  means  of  the  roller  [c  c  Fig.  3),  can  com- 
municate no  motion  either  to  the  shoulder,  or  the 
clavicle.  2dly.  The  shoulder  itself,  being  forcibly 
drawn  outward,  with  the  upper  extremity  of  the 
humerus,  by  the  action  of  the  kind  of  lever  into  which 
this  bone  is  converted,  and  to  which  the  bolster  {ab 
Fig.  1 )  serves  as  a  fulcrum,  cannot,  by  its  move- 
ments, derange  the  luxated  bone.  3dly.  The  sternal 
extremity,  being  drawn  both  by  the  muscles  which 
tend  to  displace  it  inwardly,  and  by  the  bandage 
which  acts  on  it  in  an  opposite  direction,  remains 
fixed  between  those  two  antagonizing  forces,  which 
thus  destroy  each  other.  Hence  the  apparatus  of 
Desault,  when  accurately  applied,  offers  to  both  of 
these  powers  of  displacement,  a  resistance  perfectly 
calculated  to  com.bat  them. 

20.  We  must,  however,  admit  that  this  apparatus 
partakes  of  one  inconvenience,  common  indeed  to  all 
bandages,  but  which  is  perhaps  more  particularly  ap- 
plicable to  this  in  consequence  of  the  numerous  casts 
of  the  rollers  that  form  it,  namely,  the  great  facility 


51 

with  which  it  becomes  relaxed.  Hence  one  cause  of 
displacement,  which  the  most  exact  and  sciTipulous 
attention  caimot  at  all  times  prevent. 

Case.  Desault  had,  for  a  long  time,  the  care  of 
a  patient,  whose  luxation,  having  been  neglected  for 
four  days,  was  reduced  on  the  fifth,  by  a  surgeon, 
who,  for  the  purpose  of  retaining  it,  employed  a  ban- 
dage of  a  particular  kind.  An  hour  afterwards,  a 
miotion  of  the  shoulder  backward,  displaced  the 
luxated  extremity :  a  new  reduction  was  the  conse- 
quence ;  on  the  day  following,  another  displacement, 
and  so  on  in  succession,  for  ten  days,  at  the  expira- 
tion of  which,  Desault  being  consulted,  applied  to 
the  part  the  bandage  formerly  described. 

On  being  examined  the  next  day,  the  apparatus 
M^as  found  in  a  favourable  state.  On  the  day  follow- 
ing, a  slight  displacement  rendered  necessary  a  new 
application  of  the  bandage,  which,  this  time,  conti- 
nued longer  than  before.  But,  about  the  expiration  of 
the  third  day,  the  projection  of  the  bone  was  again 
considerable.  Finally,  the  patient  recovered,  with  a 
very  perceptible  protuberance  in  front  of  the  sternum, 
and  a  difficulty  of  motion,  great  at  first,  but  less  after- 
wards, and  which  exercise  succeeded  ultimately  in 
removin.^. 

21*  The  application  of  the  apparatus  differs  fi-om 
that  intended  for  a  fracture  of  the  clavicle,  only  in 
this,  that  it  is  of  service  to  place  on  the  luxated  ex- 
tremity, graduated  compresses,*  calculated  to  make 

*  Compresses  laid  one  upon  another,  of  which  the  upper 
one  is  still  the  smallest,  not  in  relation  to  thickness,  but  as  far 
as  regards  length  and  breadth,  Trans. 


B2 

pressure  backward  and  outv/ard,  and  which  are  to  be 
secured  by  the  turns  of  the  roller  (b  Fig.  4. ) 

A  second  precaution,  not  less  essential,  is,  to 
push  the  humeral  extremity  of  the  clavicle,  a  little 
forward,  and  fix  it  in  that  direction,  in  order  that  the 
sternal  being  directed  backward,  may  be  removed 
fi-om  the  place*  through  which  it  has  a  tendency  to 
escape. 

22.  Desault  almost  always  obtained  complete 
success  by  this  process,  and  by  the  most  accurate 
attention  to  prevent  the  relaxation  of  the  bandage. 
In  the  mean  time,  a  stiffness,  more  or  less  conside- 
rable, alwa}^s  remains  in  the  joint  for  a  long  time  af- 
ter the  reduction,  and  it  is  not  unfrequently  a  month 
or  two  before  the  part  recovers  its  usual  facility  of 
motion. 

The  following  cases,  collected  by  Brochier,  con- 
firm the  doctrine  for  which  I  have  been  contending. 

Case  II.  A  man  luxated  the  clavicle  by  falling 
on  the  point  of  his  shoulder,  and  forcing  it  back- 
wai'd.  He  was  immediately  brought  to  the  Hotel- 
Dieu,  where  Desault  demonstrated  to  his  pupils, 
that  the  head  of  the  bone,  can'ied  in  fi'ont  of  the  ster- 
num., vv^as  removed  nearly  an  inch  from  its  natural 
cavit}^,  the  ligaments  of  which  were  no  doubt  lace- 
rated. 

Here,  as  in  the  fracture  of  the  clavicle,  the  appli- 
cation of  the  bandage  answered  the  purpose  of  re- 
duction, and  removed  the  protuberance  formed  by 
the  extremity  of  the  bone. 

*  The  rupture  in  the  capsule  that  surrounds  the  joint.        T. 


53 

The  patient,  being  strong  and  vigorous,  and  hav- 
ing received  besides  a  violent  contusion,  was  bied 
twice,  and  confined  to  a  low  diet.  On  the  following 
day,  no  derangement ;  on  the  fourth  day,  a  sliglit 
displacement  of  the  bone,  the  rollers  a  little  relaxed, 
bandage  applied  anevf .  Eighth  day,  no  sensible  dis- 
placement. Eleventh  day,  some  swelling  around  the 
joint ;  compresses,  wet  with  vege to- mineral  water, 
ordered  to  be  frequently  renewed.  Twentieth  day, 
the  swelling  almost  gone,  and  no  disposition  to  a 
displacement ;  the  apparatus  was  removed ;  motions 
at  first  difiicult,  and  contracted.  Tv/enty-ninth  day, 
more  free  and  easy.  Thirty-fourth  day,  returned  to 
their  natural  state. 

Case  III.  Mary  Rivert  luxated  her  clavicle,  on 
the  seventh  day  of  January  1789.  Being  brought 
some  time  afterwards,  to  the  Hotel-Dieu,  she  was 
treated  in  the  same  manner  as  the  foregoing  patient, 
and  with  the  same  result,  except  that  a  very  slight 
protuberance  remained  at  the  extremity  of  the  bone, 
and  the  confined  state  of  the  motions  continued  a 
little  longer.  Desault  related,  in  his  lectures,  other 
instances  of  cures  being  performed  without  the  least 
remaining  deformity. 

After  all,  even  supposing  the  method  just  propo- 
sed, to  possess  no  other  advantage,  than  that  of  di- 
minishing the  protuberance  of  the  bone,  winch,  un- 
der other  modes  of  treatment,  is  almost  inevitable, 
and  by  that  means  preventing  the  motions  of  the  part 
from  being  confined,  it  would  still,  v/ithout  doubt, 
be  a  great  step  towards  the  perfection  of  the  art'. 


54 

23.  Should  a  luxation  backwards  occur,  the  skme 
process  of  reduction  should  be  adopted,  with  this  dif- 
ference, that  the  extension  ought  to  be  made  forward 
and  outward;  and  the  same  apparatus  should  be  ap- 
plied for  retaining  the  paits,  except  that  the  humeral 
extreinity  ought  to  be  directed  a  little  backward,  in 
order  that  the  sternal  extremity,  being  carried  for- 
ward, may  be  removed  from  the  place  of  laceration 
in  the  capsule. 

In  like  manner,  should  the  bone  be  luxated  up- 
wards, it  would  be  necessary  to  draw  the  arm  out- 
wards, and  elevate  slightly  the  point  of  the  shoulder, 
for  the  purpose  of  depressing  the  sternal  extremity. 

LUXATION  OF  THE  HUMERAL  EXTRE- 
MITY. 

§  V. 

or    THE    KINDS   OF   LUXATION. 

24.  Luxations  of  the  humeral  extremity  of  the 
clavicle,  take  place,  according  to  Petit,  in  two  ways, 
1st,  under,  and  2dly,  over  the  acromion.  If  we  attend 
to  the  disposition  of  the  ailiculating  surfaces,  the 
superior  of  which  rests  obliquely  on  the  inferior;  if 
we  examine,  in  paiticular,  the  relative  position  of  the 
corocoid  apophysis  with  respect  to  the  clavicle,  it 
will  be  difficult  to  conceive  how  the  first  kind  of 
luxation  can  occur,  without  being  accompanied  by  a 
fracture.  Yet  some  facts  added  by  Desault  to  the 
doctrine  of  Petit,  on  this  point,  seem  to  demonstrate 
the  possibility  of  the  cla%dcle  sliding  under  the  aero- 


55 

mion.  As  to  luxations  forward  and  backward,  the 
mobility  of  the  shoulder,  the  facility  with  M^iich  it 
yields  to  motions  impressed  on  it  in  these  two  dii'ec- 
tions,  and  the  want  of  a  resisting  power,  make  the 
two  bones  that  compose  it,  move  together,  still  pre- 
serving their  relative  position. 

The  luxation  upward,  then,  is  that  which  ought 
chiefly  to  occupy  the  attention  of  the  practitioner. 
Yet  even  this  is  less  frequent  than  the  luxation  of  the 
sternal  extremity,  on  account  of  the  very  great 
strength  of  the  retaining  ligaments,  which,  when  this 
luxation  occurs,  must  be,  if  not  lacerated,  at  least 
very  much  distended. 

§  VI. 

OF   THE   MECHANISM    AND   THE   APPEARANCES. 

25.  A  fall  on  the  point  of  the  shoulder  is  the  most 
frequent  cause  of  this  luxation.  The  two  articulating 
surfaces,  representing  an  inclined  plain,  slide  along 
each  other,  in  such  a  manner,  that  that  which  belongs 
to  the  acromion  is  pushed  inward,  while  that  of  the 
clavicle  is  directed  outward.  The  capsule  being 
stretched,  gives  way,  and  then  the  displacement  is 
manifested  by  a  preternatural  protuberance  over  the 
acromion ;  by  a  stiffness  in  the  motion  of  the  shoul- 
der ;  by  the  direction  of  this  part,  which  is  evidently 
drawn  inward  and  downward;  by  the  inclination  of 
the  head  of  the  patient  to  the  side  affected;  by  a 
bending  of  the  body ;  and  by  ^severe  pains  in  tlie 
luxated  part.  These  characters  are  essentially  dis- 
tinct,   and  ought  to  have  prevented  the  error  of 


56 

Galen,  who  mistook  a  case  of  this  kind  for  a  luxa- 
tion of  the  OS  humeri  downward.  Hippocrates  and 
Ambrose  Pare  have  foreseen  the  possibilit}^  of  this 
mistake  and  even  warned  young  practitioners  to  be  eai 
their  guard  against  it.  But,  as  citizen  Sabattier  judi- 
ciously observes,  the  position  of  the  head  of  the  hu- 
merus, under  the  ai'm,  in  a  luxation  of  that  bone, 
will  remove  all  uncertamty  respecting  the  iiature  of 
the  injur}'. 

y  VII. 

or   THE   EEDUCTION^   AND   THE   MEANS  OF  RE- 
TAINING  IT. 

26.  The  reduction,  in  this  case,  is  generally  at- 
tended with  but  little  difficulty.  The  acromion  being 
drawn  outwai'd,  by  the  upper  end  of  the  os  humeri, 
which,  by  means  of  a  fulcrum  placed  under  the  ann- 
pit,  is  made  to  act  as  a  lever  of  the  first  kind,  is  re- 
stored, without  much  trouble,  to  its  natural  contact 
with  the  corresponding  surface  of  the  clavicle.  But, 
it  soon  becomes  deranged  again,  unless  it  be  retained 
in  its  place  by  a  proper  appai'atus.  Now,  on  what 
principle  ought  this  appai'atus  to  be  constructed? 
To  prevent  the  displacement,  which  generally  'oc- 
curs from  wdthout  inwards,  it  ought  evidently  to  act 
from  within  outwards.  Whence  it  follows,  that  the 
rollers  in  the  figure  of  8  bandage,  recommended  in 
this  case  by  all  ^.Titers,  instead  of  preventing,  actually 
favour  the  displacement  (17),  because  they  act  in 
the  same  direction  \^dth,  and  therefore  assist,  the 
powers  that  produce  it. 


57 

57.  Here,  in  like  manner  as  in  the  preceding 
case,  the  bandage  of  Desault  fulfils  with  precision 
the  indications  of  cure,  because,  by  it,  the  point  of 
the  shoulder  is,  particularly,  drawn  outward ;  and  if, 
in  certain  cases,  a  slight  projection  of  the  humeral 
extremity  still  remains,  it  is  to  be  attributed  to  the 
inefficacy  of  the  means  of  execution,  and  not  to  the 
principles  on  which  they  are  founded. 


MEMOIR  IV. 

ON  FRACTURES  OF  THE  ACROMION,  AND  OF  THE 
LOWER  ANGLE  OF  THE  SCAPULA. 

FRACTURE  OF  THE  ACROMION. 

1.  There  is  no  part  of  the  scapula  more  liable 
to  fractures  than  the  acromion.  Being  but  slightly 
covered  by  the  soft  parts,  this  insulated  kind  of  ap- 
pendix has  not,  in  all  positions  of  the  humerus,  a  solid 
point  of  support.  A  strong  muscular  force  oftentimes 
acts  on  it  with  great  energy.  Being  large  in  front,  it 
presents  in  that  direction  a  considerable  surface  to 
receive  the  action  of  exteiTial  bodies.  Whence  it  fol- 
lows, that  if  it  is  not  oftentimes  broken,  this  is  to  be 
attributed,  not  so  much  to  its  natural  disposition,  as 
to  the  position  which  it  generally  assumes  in  falls. 

2.  The  fracture,  which  is  almost  always  trans- 
verse, is  sometimes  at  the  summit,  and  sometimes 

9 


at  the  base  of  tliis  apophysis,  and  is  usually  produced 
by  a  violent  shock  from  a  body  falling  on  the  shoul- 
der, by  a  blow  received  on  that  part,  &c. 

3.  But  in  whatever  place  it  occurs,  it  greatly  re- 
sembles a  fracture  of  the  humeral  extremity  of  the 
clavicle,  of  which  the  acromion  appears  like  a  con- 
tinuation. There  is  accordingly  a  strong  analogy  be- 
tween the  phenomena,  the  consequences,  and  the 
modes  of  treating  these  two  kinds  of  fractures. 

4.  This  accident  is  characterized,  1st,  By  a  se- 
vere pain  experienced  by  the  patient,  at  the  place  of 
the  fracture.  This  pain  is  increased  by  the  elevation 
of  the  arm,  which,  generally  hangs  motionless  dov/n 
along  the  side.  2dly,  If  the  humerus  be  removed 
from  the  trunk,  the  hand  being  at  the  same  time  pla- 
ced on  the  acromion,  the  extremity  of  this  apophysis 
is  felt  sinking  downward,  creating  thereby  an  evident 
depression  in  the  part.  3dly,  Generally,  the  two  frag- 
mients  lose,  of  their  own  accord,  their  relative  posi- 
tion ;  and  unless  the  precaution  about  to  be  men- 
tioned be  used,  their  displacement  becomes  manifest, 
being  produced  by  the  weight  of  the  arm,  and  the 
contractions  of  the  deltoid  muscle.  4thly,  The  head 
is  inclined  to  the  affected  side. 

ui. 

OF   THE   REDUCTION. 

5.  Two  diiferent  processes  have  been  long  in 
use  for  the  reduction  of  fractures  of  the  acromion. 
One  consists  in  elevating  the  arm  almost  to  a  right 
angle  with  the  body,  in  order,  as  Heister  remarks, 


59 

to  throw  the  deltoid  muscle  into  a  state  of  relaxation, 
and  then  to  be  able,  with  the  fingers,  to  place  the 
fragments  in  their  natural  situation.  In  the  other 
mode,  the  humerus  is  sujBPered  to  retain  the  position 
it  has  assumed,  that  is,  to  hang  down  the  side  ;  the 
surgeon  then  taking  hold  of  the  elbow,  pushes  it  ver- 
tically from  below  upwards,  in  such  a  manner,  that 
the  head  of  the  bone,  pressing  against  the  acromion, 
elevates  and  replaces  it. 

6.  Petit  seems  to  have  adopted  indiscriminately- 
these  two  methods,  one  of  which,  however,  is  greatly 
superior  to  the  other.  Indeed,  it  is  evident,  that  if  the 
humerus  be  removed  from  the  trunk,  its  head  will 
necessarily  sink  down  in  the  glenoid  cavity.  Being 
thus  separated  from  the  fractured  apophysis,  it  leaves 
beneath  it  a  hollow  or  vacancy,  into  which  the  frag- 
ment will  be  pushed,  should  it  be  in  any  measure^ 
compressed  by  the  casts  of  the  roller,,  during  the  ap- 
plication of  the  bandage. 

7.  On  the  other  hand,  if  the  arm  still  fixed  against 
the  side,  be  pushed  upwards,  it  will  afford  to  the  acro- 
mion a  sohd  point  of  support,  which,^  during  the  ap- 
plication of  the  apparatus,  will  prevent  its  displacement 
downwards.  This  consideration  is  unquestionably  of 
moment,  during  the  process  of  reduction;  but  ought 
more  particularly,  to  command  the  attention  of  the 
practitioner,  in  the  choice  of  means,  destined  to  main- 
tain the  reduction. 


60 


§  III. 

OF  THE  MEANS  FOR  MAINTAINING  THE 
REDUCTION. 

8.  As  the  displacement  is  most  likely  to  occur 
downwards,  particularly  in  motions  of  the  arm,  it  is 
necessary  that  a  continued  resistance  be  opposed  to 
this  tendency.  But  this  resistance  should  be  made 
by  the  head  of  the  humerus,  which,  if  properly  direct- 
ed, will  represent,  dming  the  treatment,  a  kind  of 
splint,  which  art  ought  to  render  fixt  and  immoveable 
lest,  being  contiguous  to  the  divided  surfaces,  it  might 
derange,  by  its  motions,  the  work  of  nature  in  effect- 
ing their  reunion.  Hence  it  follows,  that  the  precise 
and  immediate  intention  of  the  whole  apparatus  des- 
tined to  support  fractures  of  the  acromion  apophysis, 
is,  1st,  to  keep  the  head  of  tlie  humerus  constantly 
elevated  or  pushed  upwards:  2dly,  carefdlly  to  pre- 
vent all  motions  of  the  arm  and  shoulder. 

9.  If  the  means,  heretofore  employed  in  this  frac- 
ture, be  examined,  it  will  be  perceived  that  they  by 
no  means  fulfil  this  tw^ofold  indication. 

A  compress  placed  immediately  over  the  fracture; 
a  roller  passed  round  this  to  secure  it ;  a  ball  or  bol- 
ster* put  into  the  hand;  the  fore-arm  supported  in  a 
sling;  such  is  the  apparatus  recommended  by  Petit. 
In  addition  to  tliis,  Duvemey  judiciously  advises  to 
keep  the  sling  elevated,  for  the  purpose  of  keeping 
the  head  of  the  humerus  applied  under  the  fractured 
pieces.  He  employed  also  the  spica-bandage  which 
has  been  equally  recommended  by  Heister. 

*  Une  pelotte. 


61  , 

10.  But,  in  the  employment  of  these  means,  the 
arm,  not  being  confined  against  the  trunk,  can  move 
with  ease,  and  derange  the  fragments,  and,  therefore, 
the  second  indication  is  not  fulfilled.  Will  even  the 
first  be  fulfilled?  By  no  means.  The  sling,  being 
soon  deranged,  by  the  movements  of  the  arm,  which 
are  oftentimes  involuntary,  suffers  it  to  sink  down 
again,  and  then  the  fi:-agments,  being  no  longer  sup- 
ported, are  displaced.  Hence  the  difficulties  attend- 
ing the  treatment,  difficulties  which  have  not  escaped 
the  notice  of  authors,  and  which  Heister  thus  ex- 
presses: ''  Nemo  ita  curari  solely  ut  hrachium  postea^ 
liberi  sursum  attollere  queat,^''  an  observation,  which 
the  celebrated  Cheselden  made  before  him,  in  de- 
scribing the  scapula. 

11.  These  inconveniences  will  be  avoided,  by 
fixing  the  arm,  as  recommended  by  Desault,  firmly 
against  the  trunk,  by  converting,  so  to  speak,  the  arm 
and  the  trunk  into  one  single  and  solid  piece,  in  such 
a  manner,  that  the  humerus  having  no  other  motions 
but  those  in  common  to  it  and  the  thorax,  may  not 
be  able  to  communicate  any  others  to  the  fragments, 
which  are  supported  by  its  head.  This  advantage 
can  be  easily  obtained,  by  means  of  the  bandage, 
already  described,  for  fi^actures  of  the  clavicle,  modi- 
fied agreeably  to  the  circumstances  of  the  case,  in 
which  it  is  to  act. 

12.  A  bolster  or  pad  of  an  equal  thickness  in  all 
its  parts,  is  placed  under  the  arm.  The  arm  is  then 
to  be  pressed  down  on  this,  in  like  manner  as  in  the 
bandage  for  the  clavicle.  The  fractured  apophysis  is 
now  to  be  covered  by  two  compresses;  one  extend- 


ing  from  the  clavicle  to  the  spinous  processes  of  the 
yertebrEe,  while  the  other,  lying  over  this,  and  run-, 
ning  in  a  contrary  direction,  crosses  it  at  the  place  of 
the  fracture.  The  whole  is  then  to  be  secured  by  a 
roller,  which,  starting  from  the  arm-pit  of  the  sound 
side,  pursues  nearly  the  same  course  with  that  destin-r 
ed,  in  fractures  of  the  clavicle,  to  retain  die  shoulder 
upwards.  (See  what  has  been  said  on  this  subject,, 
when  treating  of  the  structure  of  the  bandage.) 

13.  By  this  mean,  the  two-fold  indication  of  keep- 
ing the  humerus  immoveable,  and  directed  upwards 
(8),  is  evidently  fulfilled,  as  I  have  already  proven  at 
full  length,  when  treating  of  fractures  of  the  clavicle; 
and  a  reunion,  without  deformity,  may  be  looked  for, 
of  which  we  have  an  instance  in  the  following  casej. 
recorded  by  Derrecagaix. 

Case  I.  Nicholas  Gay,  aged  twenty-nine,  was 
struck,  in  passing  under  a  decayed  building,  by  a 
stone,  which,  having  become  loosened,  fell  on  the 
point  of  his  shoulder.  In  an  instant  he  experienced 
severe  pain,  and  a  difficulty  of  moving  his  arm,  parti- 
cularly upwards.  Soon  afterwards  there  occurred  a 
swelling  of  the  shoulder,  and  a  large  echymosis  at  the 
place  where  the  blow  was  received.  The  pain,  not 
so  acute  during  a  state  of  rest,  was  increased  by  the 
motions  of  the  arm,  and  even  by  leaning  the  head  to- 
wards the  opposite  side,  which  latter  ciscumstance- 
was,  no  doubt,  owing  to  the  contraction  of  the  trape- 
zius muscle. 

A  surgeon  being  called,  judged  it  sufficient  to^ 
make  use  of  discutient  applications,  to  which  the 
swelling  and  the  echymosis  appeared  to  yield  in  the 


63 

C6urs<t  of  a  few  days.  On  a  more  accurate  examina* 
tion,  a  fracture  was  discovered,  supposed  to  be  in  the 
external  part  of  the  clavicle,  and  for  which  the  patient 
was  sent  to  the  Hotel-Dieu. 

The  fracture  was  discovered  to  be  in  the  middle 
of  the  acromion,  which  it  divided  transversely.  The 
bandage  already  mentioned  ( 12)  was  applied,  and,  from 
the  first  day,  the  patient  was  left  to  his  usual  regimen* 
Fifdi  day,  a  renewal  of  the  apparatus  which  had  be- 
come relaxed :  seventh  day,  a  fresh  displacement,  in 
consequence  of  an  unguarded  motion :  a  fresh  appli- 
cation of  the  bandage,  which  continued  in  its  place 
till  the  sixteenth  day,  when  it  was  replaced  anew; 
thirty-second  day,  reunion  complete;  a  stiffness  in 
the  motions  of  the  part,  which  exercise  removed  by 
degrees,  and  of  which  the  patient  felt  no  remains  after 
the  forty-eighth  day. 


FRACTURE  OF  THE  LOWER  ANGLE  OF 
THE  SCAPULA. 

OF  THE   SIGNS   OR   APPEARANCES   AND   DIS- 
PLACEMENT. 

14.  Next  to  the  acromion,  the  lower  angle  of  the 
scapula  is  that  portion  of  the  bone  most  liable  to  be 
fractured.  The  usual  causes  of  it  are,  falls  on  the 
side,  or  blows  received  on  the  part.  It  is  character- 
ized by  a  displacement  which  is  always  perceptible. 
Oa  the  one  hand,  the  fleshy  portion  of  the  sen'atus- 


64 

major,  which  is  attached  to  the  inferior  fragment, 
draws  it  directly  forward,  while  it  is  di^awn  upward 
by  the  teres-major,  and  some  of  the  fibres  of  the 
latissimus  dorsi.  On  the  other  hand,  the  body  of  the 
bone  itself  remams  behind,  being  held  by  the  rhom- 
boid muscles.  Hence  arises  a  separation,  which 
renders  it  difficult  to  mistake  the  fracture.  Should 
any  doubts  still  remain,  let  the  shoulder  be  drawn 
backwards  and  the  scapula  along  with  it:  let  the  fin- 
gers be,  at  the  same  time,  placed  on  the  lower  angle, 
to  ascertain  whether  or  not  it  follows  the  motions  of 
the  bone ;  if  it  does,  there  is  no  division :  but  if,  on 
the  contrary,  it  remains  stationary,  the  existence  of 
the  fracture  is  evident. 

OF     THE     REDUCTION,    AND     THE    MEANS    OF 
RETAINING    IT. 

15.  Here,  as  in  all  other  fractures,  the  means  of 
reduction  must  be  founded  on  the  causes  of  displace- 
ment. To  effect  the  replacement,  therefore,  it  is  neces- 
sary, either  to  push  backward  and  downward,  the  an- 
gle which  is  displaced  in  a  contrary  direction,  in  order 
that  it  raay  be  brought  into  contact  with  the  body  of 
the  bone,  or  else  to  draw  the  body  of  the  bone  for- 
ward and  upward,  that  it  may  meet  the  displaced  an- 
gle. It  is  thus,  that  in  a  fracture  of  the  condyle,  the 
body  of  the  jaw,  is  drawn  into  contact  with  the  frag- 
ment. 

16.  But  the  first  mode  of  reduction  is  difficult,  and 
the  means  of  maintaining  it  impracticable.    It  is  ne- 


65 

cessary,  therefore  to  have  recourse  to  the  second, 
which  is  the  more  easily  executed,  as  the  scapula  fol- 
lows the  movements  of  the  arm,  and  as,  by  drawing 
this  hmb  forward,  and  the  elbow  of  it  outward,  that 
bone  is  removed  from  the  spinous  processes  of  the 
vertebrae,  and  directed  in  such  a  manner,  as  to  be 
brought  into  contact  with  its  inferior  fragment.  This 
situation  possesses  another  advantage,  as  it  throws  in- 
to a  state  of  relaxation  the  muscles  which  tend  to 
displace  the  lower  fragment. 

Hence  it  follows,  1st,  That  here,  in  like  manner 
as  in  fractures  of  the  clavicle,  it  is  not  on  the  fractured 
bone,  that  the  force  must  act,  but  on  the  humerus. 
2dly,  That  the  humerus  ought  to  be,  during  the 
whole  treatment,  immoveably  fixed,  because  its  mo- 
tions, being  communicated  to  the  scapula,  must  soon 
derange  the  contact  necessary  to  a  reunion. 

18.  On  these  principles  were  founded  the  appa- 
ratus of  Desault,  and  his  process  of  reduction,  which 
consisted,  1st,  in  drawing  the  arm  forward,  and  sepa- 
rating the  elbow  a  little  from  the  thorax ;  2dly,  in 
fixing  the  fore-arm  at  an  angle  sufficiently  acute,  to 
direct  the  hand  to  the  point  of  the  opposite  shoulder; 
and  3dly,  to  bring  afterwards  into  proper  apposition 
and  form,  the  fragments  already  approximated  to  each 
other  by  the  first  movements. 

19.  To  retain  this  reduction,  the  arm  and  fore-arm 
must  be  permanently  fixed  in  the  above  position.  This 
object  is  attained  in  the  following  manner,  1st,  A  bol- 
ster in  form  of  a  wedge,  being  placed  between  the  arm 
anc  the  side,  its  apex  situated  in  the  ann-pit,  affiDrds 
the  double  advantage  of  keeping  the  elbow  at  a  dis- 

10 


m 

tance  from  the  thorax,  and  of  rendering  the  position  of 
the  arm  less  fatiguing  by  serving  as  a  point  of  support 
to  it.  2dly,  Compresses  wet  with  some  discutient 
liquid,  are  apphed  on  the  part  corresponding  to  the 
fracture*  3dly,  The  whole  is  now  to  be  secured  by  a 
roller,  seven  or  eight  yards  long.  The  first  turns  of 
this  roller,  must  secure  the  hand  of  the  affeeted  side 
on  the  sound  shoulder  to  which  it  had  been  applied, 
during  the  reductioUy  and  running  afterwards  from 
before  backwards,  pass  over  the  place  of  the  fracture, 
for  the  purpose  of  retaining  the  compresses  on  it.  The 
wedge-formed  bolster  is  to  be  secured  on  the  tliorax, 
by  circular  turns  around  it.  Then,  passing  under  the 
sound  arm-pit,  after  having  made  these  cuxular  turns, 
the  roller  must  be  brought  behind  again,  conducted 
obliquely  over  the  shoulder  of  the  diseased  side,  along 
the  anterior  part  of  the  arm,  under  the  elbow,  and  be- 
hind the  thorax,  where  it  is  carried  obliquely,  in  or- 
der to  pass  again  under  the  sound  arm-pit.  From 
this  place  it  ascends  again  anteriorly  over  the  affected 
shoulder,  redescends  along  the  posterior  part  of  the 
arm,  repasses  under  the  elbow,  returns  under  the  aim- 
pit,  and  terminates  finally  in  circular  turns  round  the 
trunk,  and  arm  together.  Hence  it  may  be  observed, 
that,  in  the  first  turns  of  the  roller,  this  bandage  great- 
ly resembles  the  third  roller  applied  in  the  fracture  af 
the  clavicle,  to  retain  the  point  of  the  shoulder  up- 
ward and  backward  (Fig.  4.  plate  I.) 

20.  By  this,  1st,  The  movements  of  the  arm  be- 
ing entirely  impeded,  they  cannot  have  any  influence 
on  those  of  the  shoulder  ;  hence,  in  this  respect,  the 
fragments  are  suffered  to  remain  in  contact.  2dly, 


-    \  67 

The  serratus-major  and  teres-major  muscles,  being 
kept  in  a  state  of  habitual  relaxation,  can  no  longer 
draw  the  inferior  fragment  forward,  which  cannot, 
therefore,  be  sepai'ated  from  the  body  of  the  bone. 
3dly,  Nor  can  the  body  of  the  bone,  being  perma- 
nently held  in  this  situation,  be  removed  from  the 
fragment ;  whence,  in  both  respects,  a  displacement 
will  be  effectually  prevented.  This  threefold  advan- 
tage is  not  possessed  by  any  of  the  different  kinds  of 
apparatus  hitherto  proposed,  such  as  the  sling  and 
cross-bandage,  employed  by  Petit,  which  have  the 
fault  of  suffering  the  arm  to  move  backward,  of  al- 
lowing the  scapula  to  be  easily  se]^)arated  from  its 
insulated  angle,  of  retarding  by  that  means  the  cure, 
and  even  of  preventing  it  entirely,  while,  by  the  pro- 
cess just  described,  it  is  usually  completed  by  the 
thirtieth  day. 


MEMOIR  V. 


ON  THE  FRACTURES  OF  THE  UPPER  END  OR 
NECK  OF  THE  HUMERUS."* 

1.  The  language  of  the  surgeon  differs,  in  this 
case,  from  that  of  the  anatomist,  and  by  the  expres- 
sion, "  fracture  of  the  neck  of  the  humerus,"  is  here 

*  For  a  very  important  improvement  made  by  Dr.  Physic 
ill  the  treatment  of  an  old  fracture  of  the  os  humeri,  and  which 
may  be  appUed  also  to  similar  fractures  of  other  bones,  see  Ar- 
ticle I.  of  the  Appendix.  Tra*[s. 


68 

meant  not  that  of  the  slight  circular  depression,' 
which  separates  the  head  from  the  tuberosities  of  the 
bone,  but  rather  that  of  the  contracted  or  diminished 
portion  of  the  bone,  which  commences  at  the  tube- 
rosities above,  and  being  continued  down  the  body 
of  the  bone,  receives  at  its  lower  end  the  insertion  of 
the  tendons  of  the  pectoralis  major,  the  latissimus 
dorsi,  and  the  teres  major.  Many  practitioners  con- 
sider this  nect  or  contracted  portion  as  extending 
even  to  the  insertion  of  the  deltoid  muscle. 

2.  Several  facts,  the  truth  of  which  it  is  difficult 
to  call  in  question,  attest  the  possibility  of  a  fracture 
of  the  neck  of  the  bone,  so  called  in  anatomical  lan- 
guage. I  have  myself  seen,  in  the  humerus  of  a  young 
man,  aged  seventeen  years,  the  head  of  the  bone  ex- 
actly separated  from  its  body,  by  a  division  which 
had  but  slightly  aifected  the  upper  extremity  of  the 
tuberosities.  But  the  examples  of  this  nature  which 
occur  in  the  annals  of  surgery  are  too  few,  to  enable 
us  to  lay  down  any  general  principles  for  the  treat- 
ment of  such  fractures. 

§  II. 

OF   THE   VARIETIES   AND   THE   CAUSES. 

3.  The  operation  of  external  bodies,  active,  when 
they  are  thrown  against  the  shoulder,  passsive,  when 
the  shoulder,  or  the  arm,  is  forcibly  driven  against 
them,  is  always  the  cause  of  a  fracture  of  the  neck 
of  the  humerus.  From  the  mechanism  of  the  part, 
the  division  is  sometimes  direct,  and  sometimes  the 
effect  of  a  counter- stroke. 


69 

The  first  of  these  arises  very  generally  from  a 
fall  on  the  point  of  the  shoulder,  and  as  in  such  a  case, 
the  commotion  or  shock  must  be  very  great,  to  ex- 
tend with  sufficient  force  through  the  thick  mass 
which  forms  the  deltoid  muscle,  that  muscle  some- 
times suffers  both  contusion  and  an  echymosis. 
Blood  may  even  escape  from  a  rupture  of  some  of 
the  arteries  or  veins  of  the  joint,  and  form,  as  De- 
sault  has  observed,  a  collection  or  tumour  which  it 
would  be  imprudent  to  open. 

The  other  is  the  effect  of  a  fall  on  the  elbow, 
separated,  at  the  time,  some  distance  from  the  trunk,' 
or  on  the  hand,  which,  by  a  natural  instinct,  is  thrown 
out,  together  with  tlie  arm  and  fore -arm,  in  order  to 
break  the  violence  of  the  fall. 

4.  The  varieties  of  this  kind  of  fracture  originate, 
1st,  from  the  spot  which  it  occupies,  being  either  the 
middle  or  the  lower  part,  rarely  the  upper  part,  of  the 
neck  of  the  humerus :  2dly,  from  the  state  of  the 
surrounding  soft  parts,  which  sometimes  remain  quite 
natural,  and  at  other  times  become  distended  and 
tumefied.  This  circumstance  always  involves  the 
diagnosis  in  more  or  less  uncertainty ;  3dly,  from  the 
direction  of  the  fracture,  which  is  sometimes  trans- 
verse, but  usually  oblique,  particularly  when  pro- 
duced in  the  second  mode,  that  is,  by  a  counter- 
stroke  (3);  4thly,  fi-om  the  relative  situation  of  the 
fragments,  which  may  remain  in  contact,  an  occur- 
rence however  but  very  rare,  or  may  separate  from 
or.e  another  in  a  direction  inwardly  or  upward;  and, 
5thly,  from  different  complications,  with  which  it  may 
be  attended. 


70 
^  III. 

OF  THE   SIGNS  AND   THE    DISPLACEMENT. 

The  whole  of  the  signs  of  a  fracture  of  the  neck 
of  the  humerus,  taken  together,  characterize  its  ex- 
istence in  a  manner  sufficiently  evident.  But  it  is  not 
iilways  an  easy  matter  to  take  a  view  of  them  all  at 
once,  and  in  such  a  case,  there  are  more  difficulties 
attending  the  diagnosis  here,  than  in  any  other  jfrac- 
ture  of  the  humerus. 

An  acute  pain  is  felt  at  the  instant  of  tlie  fall ;  and 
sometimes  a  crack  or  report  is  plainly  heard.  There 
is  always  a  sudden  inability  to  move  the  hmb,  which, 
being  left  to  itself,  hangs  motionless.  But  if  any 
external  force  act  on  it,  it  yields  to  it  without  resist- 
ance, and  may  be  moved  by  it  with  great  ease  in 
every  direction. 

These  motions  are  accompanied  with  severe  pam, 
and,  if  carried  too  far,  may  give  rise  to  very  trouble- 
some affections,  as  has  been  observed  in  patients, 
where  tlie  fracture  was  mistaken  for  a  luxation. 

Beneath  the  acromion,  is  discovered  a  depression, 
always  situated  lower  down,  than  that  which  accom- 
panies the  fracture  of  that  apophysis.  If  one  hand  be 
placed  on  the  head  of  the  bone,  while  the  other  is  em- 
ployed in  moving  the  lower  fragment  in  different  di- 
rections, or,  while  an  assistant,  engaged  in  making 
the  necessary  extension,  communicates  to  this  frag- 
ment a  rotatoiy  motion,  1st,  the  head  will  be  per- 
ceived to  remain  motionless;  2dly,  the  friction  of  the 
two  divided  ends  will  produce  a  crepitation  more  or 


71 

kss  perceptible.  This  twofold  sign  is  always  deci- 
sive as  to  the  existence  of  a  fracture ;  but  the  swell- 
ing c^  the  joint  may  occasionally  prevent  the  prac- 
titioner from  availing  himself  of  it. 

The  fragments  remain  sometimes  in  contact,  with- 
out experiencing  any  displacement,  in  which  case, 
most  of  the  signs  not  manifesting  themselves,  the 
diagnosis  is  rendered  more  difficult.  But  most  fre- 
quently a  displacement  occurs,  and  then  it  is  the  in- 
ferior fragment  that  is  deranged,  and  not  the  superior 
one  which  is  so  short  that  it  can  be  but  little  effected 
by  the  action  of  the  muscles. 

7.  The  displacement  is  in  general  but  slightly 
perceptible  in  the  longitudinal  direction  of  the  bon€,> 
unless  when,  in  a  very  oblique  fracture,  the  frag- 
ments present  points  which  irritate  the  muscles,  ex- 
cite them  to  contraction,  and  augment  their  force ; 
or,  when  a  blow  of  great  violence,  continuing  to  act 
after  the  bone  is  broken,causes  the  fragments  to  over- 
lap each  other.  Thus  has  the  body  of  the  bone  been 
forcibly  drawn  upwards,  or  driven  in  the  same  direc- 
tion, till  having  passed  through  the  deltoid  muscle, 
and  the  external  integuments,  it  has  even  risen  con- 
siderably above  the  level  of  its  head. 

But  in  general,  as  Petit  observes,  the  weight  of 
the  limb  hanging  down  the  side,  opposes  to  the  action 
of  the  muscles  a  sufficient  degree  of  resistance;  and 
it  is  in  the  direction  of  the  cross- diameter  or  thick- 
ness of  the  bone,  that  the  displacement  most  frequent- 
ly occurs.  It  is  to  be  observed,  that  the  lower  frag- 
ment is  driven  either  inward  or  outward,  rarely 
in  any  other  direction.    In  the  first  case,  which  is  hy 


72 

far  the  most  common,  the  elbow  is  somewhat  remo- 
ved from  the  body,  and  cannot  be  brought  near  to 
it  without  pain;  in  the  second,  which  is  more  rarely- 
met  with,  it  is  moved  in  an  opposite  direction. 

In  the  one,  the  contractions  of  the  deltoid  muscle 
and  the  natural  curve  of  the  humerus,  in  the  other, 
the  united  action  of  the  pectoralis  major,  the  latissi- 
mus  dorsi,  and  the  teres-major,  appear  to  have  an 
essential  influence  on  the  displacement. 

In  each  case,  the  displacement  is  facilitated  by 
the  mobility  of  the  lower  fragment,  and  of  the  shoul- 
der, when  an  apparatus  from  being  improperly  con- 
structed, fails  to  prevent  the  movements  of  the  whole 
extremity. 

8  The  signs  which  have  just  been  detailed,  do 
not  always  furnish  such  luminous  evidence,  particu- 
larly to  an  inexperienced  practitioner,  as  to  prevent 
the  occurrence  of  very  serious  mistakes.  Of  this  De- 
sault  related  many  examples  in  his  lectures. 

Case.  J.  M***  Est***  falling  on  his  elbow, 
fractured  the  neck  of  the  humerus.  A  surgeon  was 
immediately  called,  who,  finding  a  depression  be- 
neath the  acromion,  a  protuberance  in  the  hollow  of 
the  arm-pit,  and  the  humerus  directed  outwards, 
pronounced,  without  further  examination,  that  there 
existed  a  luxation  in  a  downward  direction.  Wish- 
ing to  reduce  it  immediately,  he  employed,  to  no 
purpose,  the  common  processes.  Acute  pains  were 
the  consequence.  The  opening  in  the  capsule  being 
too  narrow  was  irritated,  and  the  member  subjected 
to  great  violence  of  motion.  At  length  the  pains  be^ 
came  insupportable ;  the  operators  gave  over  their 
fruitless  efforts,  and  Desault  was  called. 


73 

He  discovered  the  mistake  from  the  immobility 
of  the  head;  from  the  depression  beneath  the  acro- 
mion being  lower  down  than  in  a  luxation;  and  from 
the  existence  of  a  crepitation.  A  reduction  was 
effected  without  loss  of  time ;  the  apparatus  was  ap- 
plied, but  in  the  evening  a  considerable  swelling  oc- 
curred around  the  arm-pit ;  soon  afterwards  inflam- 
mation was  superadded ;  a  vast  collection  of  matter 
succeeded,  and,  notwithstanding  the  utmost  atten- 
tion,  it  was  five  months  before  the  patient  was  resto- 
red to  health. 

9.  To  this  example,  I  could  add  others,  where 
the  most  serious  accidents  have  resulted  from  a  simi- 
lar mistake.  It  must  be  acknowledged,  however, 
that,  if,  in  a  fracture,  the  displacement  be  inward 
and  a  little  forward,  the  greater  part  of  the  signs  here- 
in detailed  (5)  apply  equally  to  a  fracture  and  a  lux- 
ation :  but  then,  as  we  have  just  seen  in  the  prece- 
ding case,  the  immobility  of  the  head,  the  place  of 
the  depression  beneath  the  acromion,  and  the  crepi- 
tation, will  remove  any  doubts  that  may  be  excited 
in  the  mind  of  the  surgeon,  by  the  protuberance  in 
the  arm-pit,  the  direction  of  the  arm,  &c.  &c. 

UV. 

OF   THE   PROGNOSIS. 

10.  A  fracture  of  the  neck  of  the  humerus  as- 
sumes, in  general,  a  character  not  very  troublesome ; 
and  if,  as  Heister  says,  "  a  fracture  near  the  head  is 
worse,  and  more  difficult  to  be  cured,"  this  is  less 
owing  to  the  nature  and  seat  of  the  disease,  than  ta 
the  difficulty  of  keeping  the  fragments  in  contact, 

11 


74 

Seldom  have  the  reunion  of  the  bone,  and  the 
removal  of  all  the  disagreeable  eifects  accompanying 
the  accident,  required  a  longer  time  than  is  necessary 
for  the  cure  of  other  fractures.  The  numerous  ex- 
amples, which  occurred  in  the  Hotel-Dieu,  during 
Desault's  direction  of  the  surgical  department,  con- 
firm the  truth  of  this  assertion,  notwithstanding  some 
doubts  that  may  have  been  raised  respecting  it,  by 
prejudices  formerly  entertained,  on  the  subject  of 
fractures  in  the  vicinity  of  joints. 

From  twenty- six  to  thirty  days  are  sufficient  for 
the  reunion  :  this  was  tlie  term  commonly  required 
in  the  Hotel-Dieu. 

11.  If  judiciously  managed,  art  readily  removes 
all  the  accidents  attendant  on  this  fracture ;  but,  if 
otherwise,  the  consequences  ai-e  apt  to  prove  trou- 
blesome. It  is  here,  much  more  particularly  than  in 
other  places,  that  all  deformity  of  the  part  ought  to 
be  prevented;  because,  the  neck  of  the  humerus  be- 
ing near  to  the  centre  of  the  motions  of  the  arm,  will 
very  essentially  impede  those  motions  if  it  be  not 
properly  reunited.  A  deformed  callus  has  been  known 
to  produce,  in  the  hollow  of  the  arm-pit,  a  protube- 
rance, which  has,  in  part,  prevented  abduction,  and 
appeared  to  keep  up  an  habitual  swelling  in  the  limb. 

It  is,  then,  from  the  perfection  of  the  appai'atus, 
and  not  from  the  vicinity  of  the  injury  to  a  joint, 
that  the  prognosis  is  to  be  formed,  both  as  to  the 
consequences,  and  as  to  the  duration  of  the  fracture. 
Keep  the  fragments  in  exact  and  regular  contact,  and 
there  will  be  no  obstacle  to  that  success  which  sel- 
dom forsook  Desault. 


75 

OF   THE    REDUCTION. 

12.  The  reduction  in  this  case  is  usually  attend- 
ed with  but  little  difficulty,  and  the  great  multiplicity 
of  means  hitherto  used  for  that  purpose,  demonstrate 
only  the  barrenness  of  the  art. 

Most  of  the  machines  destined  to  reduce  the 
luxation  of  the  humerus,  have  been  applied  to  this 
fracture.  Thus  the  ladder,*  the  door,f  and  the 
club,  J  placed  under  the  arm-pit,  served  at  once  the 
purposes  of  counter-extension,  and  conformation, 
while  the  powers  for  producing  extension  were  ap- 
plied to  the  elbow,  and  more  rarely  to  the  wi'ist. 
Thus  Hippocrates  recommended  a  wooden  cross, 
the  effect  and  mode  of  action  of  which  are  nearly  the 
same.  These  means,  in  general,  besides  being  insuf- 
ficient, are  liable  to  a  further  objection,  in  conse- 
quence of  their  acting  on  the  edges  of  the  pectoralis 
major,  latissimus  dorsi,  and  teres  major,  which  being 
thus  forced  upwards,  draw  the  fragment  to  which 
they  adhere  in  the  same  direction,  and  thereby  con- 
stitute an  obstacle  to  the  reduction.  (See  what  will 
be  advanced  on  the  subject  of  luxations  of  the  hu- 
merus.) 

13..  To  machines  succeeded  the  use  of  straps, 
weights  suspended  to  the  limb,  &c.  These  processes 

(*  L'echelle,  f  la  porte,  |  le  baton.)  These  pieces  of  ma- 
chinery, though  formerly  in  use,  are  now,  I  believe,  in  all  parts 
of  the  world,  laid  aside.  It  would  be  superfluous,  therefore,  to 
consume  time  in  describing  either  them,  or  their  mode  of 
operation.  Trans. 


'76 

were  entirely  useless,  in  as  much  as  they  were  Intend- 
ed only  to  increase  the  natural  powers  of  the  operator, 
which  are  already  more  than  sufficient  of  themselves. 
They  will,  therefore,  in  a  short  time,  exist  only  in  the 
history  of  surgery. 

Petit  proposed  to  reduce  this  fracture,  by  first 
raising  the  arm  to  a  right  angle  with  the  body,  and 
then  directing  one  assistant  to  make  the  requisite  ex- 
tension, by  taking  hold  of  the  elbow  with  his  hands, 
while  another  grasped  the  point  of  the  shoulder,  for 
the  purpose  of  counter-extension.  This  method  was 
attended  with  the  threefold  inconvenience,  of  subject- 
ing the  patient  to  great  fatigue  and  pain,  of  weaken- 
ing the  extending  powers,  by  bringing  them  too  near 
to  the  point  required  to  be  moved,  and  of  irritating 
the  muscles  that  draw  the  lower  fragment  upwards, 
and  thus  exciting  them  to  contract.  Hence  the  diffi- 
culties sometimes  attendant  on  reduction,  which  is 
always  simple  in  itself,  when,  after  the  trunk  is  pro- 
perly fixed,  gentle  extensions  are  made  by  taking 
hold  of  the  fore-arm  in  a  half-bent  state.  The  follow- 
ing is  the  mode  of  reduction  practised  by  Desault. 

14.  The  patient  is  seated  either  on  a  chair  or  on 
the  side  of  a  bed.  The  arm  is  slightly  separated  from 
the  body,  and  carried  a  little  forward. 

One  assistant  is  directed  to  fix  and  secure  the 
trunk  in  a  proper  manner.  This  he  does  by  pulling 
at  the  arm  of  the  sound  side,  taking  hold  of  it  near  to 
the  hand,  and  extending  it  in  a  direction  perpendi- 
cular to  the  axis  of  the  body.  This  mode  of  counter- 
extension  is  preferable  to  that  commonly  employed, 
which  consists  in  applying  the  hands  to  the  upper  part 


77 

of  the  patient's  shoulder.  Indeed,  on  the  one  hand, 
the  power  being  farther  removed  from  the  resisting 
force,  need  not  be  so  great.  And,  on  the  other,  the 
body  being  entirely  unencumbered,  renders  it  easy 
for  the  surgeon  to  apply  the  roller  without  disconti- 
nuing, or  in  any  way  disturbing,  the  extension. 

Another  assistant  makes  extension  on  the  fore- 
arm, which  serves  him  as  a  lever,  where,  one  hand 
being  placed  behind  or  on  the  back  of  the  wrist, 
forms  the  point  of  support,  (or  fulcrum),  while  the 
other  applied  to  the  anterior  and  middle  part  of  the 
fore  arm,  on  which  it  makes  pressure  from  above 
downward,  represents  the  power;  the  fragments  to 
be  brought  into  contact  constitute  the  resistance. 

The  relaxation  of  the  muscles  produced  by  this 
semi- flexion  of  the  fore-arm,  and  the  slight  separation 
of  the  arm  from  the  trunk,  greatly  favour  this  mode 
of  extension;  a  mode  recommended  by  the  ancients, 
adhered  to  by  the  English,  and  which  possesses  the 
advantage  of  leaving  uncovered  all  that  portion  of  the 
limb  on  which  the  apparatus  is  to  be  applied,  and  by 
that  means  of  allowing  the  hands  of  the  assistant  to 
keep  the  same  position  during  the  whole  time  of  the 
application, 

A  small  degree  of  force,  judiciously  directed  ac- 
cording as  the  displacement  is  inward  or  outward,  is 
sufficient  to  effect  the  reduction,  which  even  takes 
place  of  its  own  accord,  under  this  process.  If  the 
surgeon  lays  his  hands  on  the  place  of  fracture,  it  is 
rather  to  examine  the  state  of  the  fragments,  than  to 
assist  in  bringing  them  into  apposition. 


78 


§VI. 

OF    THE    MEANS    OF    MAINTAINING    THE 
REDUCTION. 

16.  All  kinds  of  apparatus  for  fractures,  being 
nothing  but  resistances  opposed  by  art,  to  the  powers 
which  produce  displacement,  it  follows,  that  they 
should  all  act  in  directions  precisely  opposed  to  the 
directions  of  those  powers.  But,  we  have  seen  (7), 
that,  in  the  present  case,  these  powers  are,  1st,  the 
action  of  external  bodies,  favoured  by  the  extreme 
mobility  of  the  arm  and  shoulder;  2dly,  the  action 
of  the  latissimus  dorsi,  the  pectoralis  major,  and  the 
teres  major,  which  carry  the  inferior  fragment  inward, 
or,  what  is  more  common,  of  the  deltoid  muscle, 
which  draws  it  outward ;  3dly,  the  contractions  of 
the  muscles  of  the  arm,  which  have  a  slight  tendency 
to  draw  the  same  fragment  upwards. 

17.  Therefore,  1st,  to  render  the  arm  and  shoul- 
der immoveable ;  2dly,  to  carry  the  upper  end  of  the 
lower  fragment  outward  or  inward,  according  to  the 
direction  in  which  it  is  displaced;  and,  3dly,  to  draw 
this  fragment  downward,  are  the  three  indications 
that  ought  to  be  fulfilled  by  every  bandage  intended 
for  a  fracture  of  the  neck  of  the  humerus.  The  last 
merits  less  attention  than  the  other  two,  because,  as 
already  observed,  the  weight  of  the  limb  alone  is 
nearly  sufficient  to  answer  it. 

18.  Let  us  inquire,  whether  or  not  the  kinds  of 
apparatus,  hitherto  employed,  have  been  adequate  to 
the  fulfilment  of  these  indications. 


79       , 

The  ancients,  in  obedience  to  the  precept  of  Hip- 
pocrates, fixed  the  arm  against  the  breast,  and  con- 
fined it  there  by  a  bandage  recommended  by  Celsus, 
and  constantly  employed  by  Paul  of  Egina.  "  Prees- 
tat  antem^  says  he,  brachium,  ad  thoracem  moderate 
deligare ^  ut ne ^  slid commoveatur,  figurama^ertat.'''' 
Pare  still  preserved  this  process,  which  the  modems 
have  now  entirely  abandoned,  and  which,  taken  alone, 
could  properly  fulfil  only  the  first  indication.  The 
second  indication  was  less  happily  fulfilled,  by  a  kind 
of  bandage  added  to  the  first,  by  Celsus,  Paul  of 
Egina,  and  the  Arabians,  the  necessary  effect  of  which 
was,  to  force  the  lower  fragment  outwards.  It  is 
surprising  that  Heister  and  Lamotte  should  have  con- 
fined themselves  to  the  use  of  this  for  the  retention 
of  the  fragments. 

What  shall  we  say  of  the  eighteen-tailed  bandage 
exclusively  adopted  by  Petit  and  Duverney  ?  The 
arm,  not  being  fixed  by  it,  was  liable  to  be  moved, 
and  the  fragments  to  be  displaced  by  the  least  shock. 
There  was  nothing  to  prevent  the  lower  fragment 
from  obeying  the  powers  tending  to  carry  it  either 
inward  or  outward.  Indeed  the  bandage  was  of  no 
avail  whatever  in  giving  support  to  a  fracture,  as  was 
observed  by  Louis,  in  his  "  Dissertation  on  Petit's 
Diseases  of  the  Bones. ' ' 

Suppose  the  arm,  as  some  have  advised,  to  be 
supported  only  by  a  sling.  Not  one  of  the  indications 
just  established  (17)  could  by  such  means  be  fulfilled. 

Perhaps  the  bolster  of  tow  proposed  by  Moscatti, 
would  have  surpassed  all  these  means,  in  the  advan- 
tages it  offered,  had  it  not,  by  leaving  the  arm  move- 


able  below,  and  the  shoulder  above,   still  favoured  a 
displacement. 

Le  Dran  has  also  advised  the  use  of  a  bolster 
composed  of  that  of  Moscatti,  and  bole  Armenian. 
It  fixed  the  arm  more  firmly  against  the  trunk  and 
in  this  respect,  certainly  approached  nearer  to  the 
attainment  of  the  object  in  view. 

19.  It  is  obvious,  from  this  comparison  between 
the  indications  of  cure  (17),  and  the  means  hitherto 
employed  for  the  fulfilment  of  them  (18),  that  nothing 
satisfactory  had  yet  been  done,  and  that  a  proper  ap- 
paratus was  still  a  desideratum.  The  success  expe- 
rienced by  Desault,  in  the  use  of  that  which  we  are 
about  to  describe,  has  perhaps  proven,  that  this  desi- 
deratum exists  no  longer. 

20.  The  pieces  which  compose  it,  are,  1st,  Two 
rollers,  the  one  from  five  to  six,  and  the  other  fi'om 
eight  to  ten  yards  long,  each  one  about  three  inches 
wide :  2dly,  Three  strong  splints,  of  different  lengths, 
each  about  two  inches  broad :  3dly,  A  small  bolster 
made  of  linen,  from  three  to  four  inches  thick,  at  one 
end,  tapering  like  a  wedge  to  the  other,  and  of  a  suffi- 
cient length  to  reach  from  the  arm-pit  to  the  elbow; 
4thly,  A  sling  for  the  purpose  of  supporting  the  fore- 
arm; 5thly,  A  piece  of  linen  to  surround  the  whole 
apparatus. 

Every  thing  being  properly  arranged,  the  reduc- 
tion, effected  in  the  manner  already  stated  (14),  and 
the  assistants  still  continuing  the  extension : 

1st,  The  surgeon  takes  the  first  roller,  wet  with 
vegeto-mineral  water,  fixes  one  end  of  it  by  two  cir- 
cular turns  on  the  upper  part  of  the  fore-arm,  and 


81 

carries  it  up  along  the  arm  by  oblique  turns,  mode- 
rately tight,  and  overlapping  each  other  about  two- 
thirds  of  their  breadth.  Having  reached  the  upper  part 
of  the  limb,  he  m.akes  some  reversed  turns  to  pre- 
vent the  wrinkles  that  would  be  caused  by  the  une- 
venness  that  occurs  in  this  place.  He  then  passes  two 
casts  of  the  roller  under  the  opposite  arm-pit,  and 
bringing  the  ball  to  the  top  of  the  shoulder  again, 
gives  it  into  the  hand  of  an  assistant. 

2dly,  The  fxrst  splint  is  then  placed  before,  and 
reaches  from  the  fold  of  the  arm,  to  a  level  with  the 
acromion.  The  second  on  the  outside,  reaching  from 
the  external  condyle  to  the  same  level.  The  third  be- 
hind, reaching  from  the  olecranon  to  the  fold  of  the 
arm-pit.  The  bolster  placed  between  the  arm  and 
the  thorax  is  a  substitute  for  a  fourth  splint,  which 
is  by  that  rendered  unnecessary.  An  assistant  now 
secures  them,  by  grasping  them  with  his  hand  to- 
wards the  curvature  of  the  elbow,  so  as  not  to  hinder 
die  application  of  the  remaining  part  of  the  bandage. 

3dly,  The  surgeon  takes  hold  of  the  roller  again, 
descends  by  oblique  and  reversed  turns  along  the 
splints,  which  he  fixes  by  binding  them  moderately 
tight,  and  terminates  the  bandage  at  the  upper  part 
of  the  fore-arm,  where  he  had  commenced. 

4.  The  assistants  stiU  continuing  the  extension, 
the  surgeon  places  the  bolster  between  the  arm  and 
the  trunk,  taking  care  that  the  thick  end  be  upper- 
most, if  the  displacement  be  in  an  inward  direction, 
but  lowermost,  if  it  be  in  an  outward  one,  as  is  most 
commonly  the  case  (7).  The  bolster  is  to  be  fastened 

at  top  by  two  pins  to  a  cast  of  the  roller. 

12 


82 

5.  The  arm  is  now  pressed  towards  the  trunk, 
and  fixed  against  the  bolster,  by  means  of  the  second 
roller.  This  roller  is  applied  like  that  which,  in  frac- 
tures of  the  clavicle,  fastens  down  the  arm  to  the  bol- 
ster, by  the  oblique  turns  c.  c.  (Fig.  3.  plate  I.),  with 
this  difference,  that  in  the  present  case,  the  turns 
ought  to  be  very  tight  below,  and  looser  above,  if 
the  displacement  be  in  an  inward  direction.  But,  on 
the  other  hand,  if  it  be  outwardly,  they  must  be  loose 
below,  and  tight  above. 

6.  The  fore-arm  is  now  to  be  suspended  in  a  sling, 
and  the  whole  apparatus  afterwards  surrounded  by  a 
piece  of  linen,  which,  by  protecting  the  casts  of  the 
roller  from  friction,  prevents  them  from  being  dis- 
turbed. 

21.  If  we  now  compare  the  action  of  this  appara- 
tus with  tlie  indications  of  cure  formerly  laid  down 
(17),  it  will  be  easy  to  perceive,  that,  by  it,  they  are 
extremely  well  frilfilled.  Indeed,  the  arm,  being 
firmly  fixed  against  the  tnmk,  cannot  move,  other- 
wise than  by  motions  common  to  it  and  the  trunk, 
and  nothing  can  derange  the  lower  fragment,  which 
is  equally  immoveable.  Nor  can  the  shoulder  com- 
municate any  motion  to  tlie  superior  fragment.  The 
bolster  being  differently  disposed,  according  to  the 
direction  in  which  the  lower  fragment  is  displaced, 
will  serve  to  move  it  in  an  opposite  direction. 

Should  this  fragment  be  forced  inwards,  the  thick 
head  of  the  bolster  will  separate  it  to  a  distance  from 
the  thorax.  It  will  be  maintained  in  this  state  of  se- 
paration, by  the  casts  of  the  roller,  .which,  being  very 
tight  below,  will  act  on  it  as  on  a  lever  of  the  first 


83 

kind,  of  which  the  bolster,  forms  the  fulcrum,  while 
the  resistance  to  be  overcome  is  the  action  of  the 
latissimus  dorsi,  the  pectoralis  major  and  the  teres 
major.  The  casts  of  the  roller,  by  pressing  the  elbow 
to  the  body,  will  draw  the  fractured  end  of  the  bone 
in  a  contrary  direction;  and,  in  this  respect,  the  ban- 
dage may  be  considered  as  an  artificial  muscle,  form- 
ing a  perfect  antagonist  to  the  natural  ones. 

22.  If  the  displacement  be  in  an  external  direc- 
tion, as  most  commonly  occurs  (7),  a  contrary  effect 
must  be  produced,  as  well  by  the  pressure  made  by 
the  bandage,  on  the  upper  extremity  of  the  displaced 
fragment,  as  by  the  situation  of  the  elbow  which  is 
directed  outwards  by  means  of  the  tliick  end  of  the 
bolster  being  placed  lowermost.  The  external  splint 
will  also  prevent  the  displacement  outwards,  as  well 
by  opposing  to  the  bone  a  mechanical  resistance,  as 
in  compressing  the  deltoid  muscle,  which  is  the 
principal  cause  of  the  displacement.  The  derange- 
ment of  the  lower  fragment  forward  and  backward, 
will  be  prevented  by  the  two  splints  before  and  be- 
hind. 

The  displacement  longitudinally,  already  checked 
by  the  weight  of  the  limb,  will  be  still  further  pre- 
vented, by  the  compression  made  on  the  muscles  of 
the  arm,  which  are  the  instruments  of  displacement, 
by  the  splints  and  the  bandage. 

23.  To  the  advantage  of  keeping  the  fragments 
exactly  in  place,  this  apparatus  unites  that  of  not  con- 
fining the  patient,  who  is  not  obliged  to  keep  liis  bed, 
and  to  whom  a  lying  position  is  even,  in  general,  more 
troublesome  and  injurious  than  an  erect  one.    This 


84 

observation  applies  to  the  treatment  of  fractures  of  the 
oiavicle,  of  the  scapula,  and  even  of  the  fore-arm, 
when  no  accident  has  rendered  them  complicated. 

Desault  has  cured  several  patients,  but  more  par- 
ticularly two,  vi^ho,  being  obliged  to  travel  daily,  did 
not,  except  on  the  day  of  the  accident,  deviate  in  any 
measure  from  their  usual  mode  of  life. 

,^  An  inexperienced  surgeon  sometimes  applies  the 
rollers  too  tight,  in  which  case,  a  swelling  of  die  fore- 
arm is  the  consequence.  This  is  remedied  by  relax- 
ing the  bandage;  but  if,  notwithstanding  this,  the 
swelling  still  continues,  it  will  be  necessary  to  extend 
the  bandage  from  the  hand  to  the  shoulder. 

§  VII. 

or   THE   SUBSEQUENT   TREATMENT. 

24.  The  pain  ceases  as  soon  as  the  apparatus  is 
applied,  because  the  fragments,  now  brought  into 
perfect  contact,  cease  to  irritate  the  sun'ounding  parts. 
Nor  does  it  return  during  the  treatment,  as  they  are 
firmly  retained,  and  not  suffered  ag-ain  to  separate. 

It  is  rare  that  any  serious  accident  follows  this 
fracture,  and,  among  the  numerous  examples  met 
with  by  Desault,  he  has  scarcely  ever  had  one  such 
to  encounter :  yet  he  generally  paid  but  little  atten- 
tion to  those  internal  means  which  are  usually  com- 
bined with  external  ones.  In  most  cases,  the  patients 
pursued  the  regimen  to  which  they  had  been  accus- 
tomed. 

In  cases,  where  a  considerable  swelling  attacked 
tiie  upper  part  of  the  joint,  a  circumstance  which 


85 

occasionally  occurs  in  practice,  one  or  two  bleedings, 
a  diet  more  or  less  strict,  and  the  use  of  diluent 
drinks,  constituted  the  internal  treatment.  Of  this 
the  following  case,  related  by  Brochier,  furnishes  a 
detail. 

Case  II.  Maria  Catharine  BardeHe,  aged  forty- 
five,  of  a  high  complexion,  fell,  as  she  was  carrying 
a  heavy  load,  on  the  elbow  of  the  right  side,  the  arm 
being  extended  a  little  from  the  body.  The  neck  of 
the  humerus  was  fractured,  and  all  the  usual  signs 
combined  in  pointing  out  the  nature  of  the  accident. 

A  surgeon  was  immediately  called,  who  mistak-* 
ing  it  for  a  luxation,  made  useless  attempts  to  reduce 
it,  tormented  the  patient  for  half  an  hour,  and  then 
left  her  to  be  sent  to  the  Hotel-Dieu. 

Desauit  discovered  it  at  first  sight  to  be  a  fracture, 
and  foreseeing  the  consequences  of  the  improper 
steps  that  had  been  taken,  ordered  blood-letting,  and 
a  low  diet,  after  having  effected  the  reduction,  and 
applied  the  apparatus  already  described  (20). 

In  the  evening,  a  considerable  swelling  appeared 
around  the  articulation;  the  pains  continued;  a  dilut- 
ing di'ink  composed  of  dog- grass  and  oxymel  was 
prescribed.  Second  day,  the  sv»^elling  is  gaining 
ground;  pains  increased;  blood  drawn  again;  diet 
and  drink  continued;  apparatus  is  frequently  wet 
with  vegeto-mineral  water,  particularly  at  the  upper 
part.  Third  day,  a  little  better;  pains  diminished, 
swelling  checked;  weak  soup  is  allowed.  Fourth 
day,  a  diminution  of  the  swelling;  pains  almost  gone. 
Sixth  day,  the  swelling  has  almost  disappeared;  light 
food;  bandage,  having  become  loosened,  is  reapplied. 


86 

Tenth  day,  tongue  foul ;  nausea;  want  of  appe- 
tite; symptoms  of  a  bilious  diathesis.  Bitter  drink 
is  prescribed;  the  day  following,  a  grain  of  tartar 
emetic  is  given  in  solution. 

Thirteenth  day,  the  patient  is  in  her  ordinary 
state;  the  apparatus  is  renewed.  Twenty-fourth  day, 
the  reunion  is  evidently  advancing.  Thirty- second 
day,  the  consolidation  is  complete. 

The  patient  now  begail  to  perform  gentle  mo- 
tions with  the  limb,  which  she  gradually  increased, 
till  about  the  fortieth  day,  when  she  was  perfectly 
well,  and  free  in  all  her  motions. 

25.  I  will  here  repeat  an  observation,  already 
made,  on  the  subject  of  the  bandage  for  the  clavicle, 
of  which  this  is  nothing  else  than  a  modification.  In 
a  short  time  the  bolster  sinking  downward,  the  ban- 
dage becoming  relaxed,  and  the  splints  less  tight,  do 
not  eifectually  oppose  a  displacement,  unless  the  ban- 
dage be  daily  examined,  and  reapplied,  when  it  seems 
to  act  too  feebly.  There  are  many  surgeons,  who 
have  not  been  fortunate  in  retaining  the  fragments 
with  exactness,  because,  trusting  too  far  to  the  action 
of  the  bandage,  they  have  for  a  long  time  neglected 
to  examine  it ;  this  remark  is  applicable  to  every 
apparatus  composed  of  rollers. 

26.  Here,  much  more  than  in  other  cases,  it  is 
all- important  that  the  limb  be  accustomed  to  motion, 
after  the  process  of  consolidation.  Situated  near  to 
the  joint,  the  fracture  always  leaves  some  stiffiiess  in 
it,  which  time  no  doubt  wears  away,  but  which  will 
sooner  disappear  under  the  above  treatment. 


87 
§  VIII. 

REMARKS  ON   COMPLICATED  FRACTURES. 

27.  Complicated  fractures  of  the  neck  of  the  hu- 
merus are  to  be  classed  with  all  other  accidents  of  a 
similar  nature,  and  it  would  be  difficult  here  to  lay 
down  such  general  rules  as  would  be  applicable  to 
every  case.  The  practitioner  must  be  always  govern- 
ed by  circumstances.  The  necessity  of  the  case 
sometimes  urges  him  to  the  adoption  of  daring  mea- 
sures, which,  in  developing  the  resources  of  the  art, 
do  honour  to  the  talents  of  him  who  exercises  it.  Of 
this  the  following  case  is  a  proof. 

Case  III.  Pierre  Lena,  aged  fifteen,  as  he  was 
at  work  on  a  scaffold,  forty  feet  from  the  ground,  fell 
from  that  height  on  the  comer  of  a  stone.  He  expe- 
rienced instantly  such  severe  pains ^  that  he  was  una- 
ble to  rise.  He  was  carried  to  the  house  of  a  surgeon, 
who,  believing  that  he  had  suffered  a  luxation,  made 
fruitless  attempts  to  reduce  it,  produced  in  the  part 
an  enormous  swelling,  augmented  his  pains,  and  all 
to  no  purpose. 

The  patient  was  carried  to  the  Hospital  of  Chari- 
ty, where  Desault  at  the  time  was  surgeon  in  chief. 
A  fracture  of  the  neck  of  the  humerus  was  discover- 
ed, through  the  tumefaction  and  echymosis,  which 
had  overspread  the  whole  shoulder.  A  suitable  ban- 
dage was  applied. 

A  few  days  afterwards,  a  manifest  fluctuation,  an 
evidence  of  an  effusion  of  blood,  disclosed  the  neces- 
sity of  making  an  opening.  This  was  accordingly 
done,  and  the  fingers  being  introduced  into  the  part. 


88 

several  large  splinters  were  discovered,  and  a  sharp- 
pointed  bone,  the  end  of  the  lower  fragment,  pricking 
the  deltoid  muscle,  and  occasioning,  no  doubt,  the 
pains  which  had  hitherto  continued  without  inter- 
mission. 

The  indication  was  evident.  To  give  vent  to  all 
the  splinters,  and  cut  off  the  pomt  of  the  bone,  or  to 
amputate  the  limb,  was  the  only  alternative  that  was 
left.  Most  of  the  practitioners  that  were  consulted 
were  in  favour  of  the  last  measure.  But  Desault  ven- 
tured to  repose  a  hope  in  the  first,  the  successful  is-» 
sue  of  which  would  be  the  certain  preservation  of 
the  limb.  He  performed  the  operation  as  follows. 

A  large  incision  made  in  the  posterior,  and  one 
stiU  larger  in  the  anterior  part  of  the  arm,  enabled 
him  to  remove  with  ease  all  the  splinters.  Then  ta- 
king hold  of  the  pointed  extremity  of  the  inferior 
fragment,  he  drew  it  through  the  anterior  opening, 
and  cut  it  off  with  a  saw  and  a  pair  of  cutting  forceps. 
He  then  replaced  it  with  his  fingers,  and  fixing  the 
head  of  the  bone  in  its  proper  position,  applied  an 
apparatus  somewhat  similar  to  that  intended  for  the 
retention  of  fractures. 

A  suppuration  taking  place,  the  patient  was  dres- 
sed every  day.  Several  abscesses  were  formed  duiing 
the  course  of  the  treatment ;  each  time  the  pus  was 
discharged  by  means  of  an  incision. 

At  the  end  of  four  months,  the  bone  was  perceiv- 
ed to  be  in  a  state  of  necrosis.  The  dressings  were 
regularly  continued ;  but  the  patient,  becoming  tired 
of  his  residence  in  the  hospital,  left  it,  being  able  to 
move  without  difficulty,  and  having,  in  the  upper 


89 

part  of  his  ami,  a  deep  fistula,  from  v^Ahence  there  was 
a  constant  escape  of  ichorous  matter,  and  through 
which  several  splinters  were  discharged,  in  the  space 
of  six  months  which  he  passed  at  his  own  house. 

About  the  expiration  of  this  period  he  returned 
to  the  Hospital  of  Charity.  Desault  had,  in  the  mean 
time,  left  this  institution  to  take  charge  of  the  Hotel- 
Dieu.  Amputation  was  proposed  to  the  patient  as  his 
only  resource.  He  refused  to  comply,  and  went  to 
Desault,  who,  examining  the  state  of  the  parts,  found 
an  irregular  callus  formed,  which  he  removed,  toge- 
ther with  a  portion  of  the  soft  parts  corresponding  to 
the  jfracture.  At  the  end  of  two  months  and  a  half, 
the  patient  was  dischai'ged  perfectly  cured,  except  a 
weakness  in  the  limb,  which  disqualified  him  for  hard 
labour. 

28.  This  case  may  thi^ow  considerable  Jight  on 
the  difficult  question  relative  to  amputations  at  the 
joint.  But  this  is  not  the  place  to  state  the  ideas  of 
Desault  on  that  point  of  practice. 

I  will  only  observe,  that  in  many  cases  of  gun- 
shot wounds,  a  similar  treatment  would  probably 
save  life,  without  exposing  the  wounded  to  the  dan- 
gers of  an  operation,  in  which  so  considerable  a  por- 
tion of  the  system  cannot  be  removed  with  impunity, 
and  would  secure  to  them  a  limb,  for  the  preservation 
of  which  they  ought  not  to  shrink  from  the  pains  and 
hazards  of  a  tedious  treatment.  To  sacrifice  a  part 
for  the  preservation  of  the  whole,  is  tlie  last  resource 
of  the  art.  It  is  necessary,  before  resolving  on  this, 
to  exhaust  those  previous  ones  that  might  restore  the 
whole  of  our  organs  to  life  and  their  proper  functions. 

13 


90 


MEMOIR  VI. 

ON  THE  FRACTURE  OF  THE  LOWER  EXTREMITY 
OF  THE  HUMERUS,  WITH  A  SEPARATION  OF 
THE   CONDYLS. 

1.  Fractures  of  the  humerus,  accompanied 
with  a  separation  of  the  condyls,  appeal'  to  have 
escaped  the  notice  of  most  authors  who  have  written 
on  diseases  of  the  bones.  The  ancients  have  trans- 
mitted nothing  to  us  on  this  point.  Petit,  Duverney, 
and  Bell,  among  the  moderns,  have  made  no  mention 
of  it.  Heister  adverts  to  this  fracture  of  the  bone, 
only  to  express  an  unfavourable  prognostic  respecting 
it,  without  determining  the  mode  in  which  it  is  to  be 
remedied.  Yet  it  is  by  no  means  rare  to  meet  with 
examples  of  it  in  practice.  Desault,  in  particular, 
has  had  frequent  occasions  to  observe  it. 

OF   ITS  VARIETIES  AND    SIGNS. 

2.  These  fractures,  like  those  of  the  condyls  of 
the  OS  femoris,  are  rarely  the  effect  of  a  counter- stroke. 
They  are  almost  always  produced  by  the  immediate 
action  of  external  bodies;  such,  for  instance,  as  a  fall 
on  die  joint  of  the  arm ;  the  wheel  of  a  caiTiage  pass- 
ing over  this  part,  &c.  &c. 

3.  Whatever  may  be  their  cause,  they  generally 
occur  in  such  a  manner,  that  a  longitudinal  division 
separates  the  condyls  from  each  other,  and,  extending 


91 

upwards  to  a  greater  or  less  distance,  is  terminated  by 
another  transverse  or  oblique  division,  w^hich  passes 
through  the  whole  thickness  of  the  body  of  the  bone, 
so  that  there  are  three  fragments,  and  two  fractures. 

4.  Sometimes  the  division  is  simple;  in  which 
case,  being  directed  outwards  or  inwards,  it  crosses 
the  lower  end  of  the  humerus,  obliquely  from  above 
downwards,  and  terminating  at  the  joint,  separates 
but  one  of  the  condyls  from  the  body  of  the  bone, 
leaving  the  other  adhering  to  it. 

5.  In  the  first  case  (3),  there  is  more  deformity 
at  the  broken  extremity  of  the  humerus;  and  the 
mobility  is  also  greater.  If  the  fingers,  placed  before 
or  behind,  press  on  the  limb  in  the  direction  of  the 
longitudinal  fracture,  the  two  condyls  will  be  separa- 
ted from  each  other,  the  one  yielding  in  an  outward, 
and  the  other  in  an  inward  direction,  leaving  a  fissure 
or  opening  between  them.  The  part  at  the  same  time 
expands  in  breadth.  Thus,  the  two  condyls  of  the 
OS  femoris,  are  seen  to  separate  from  each  other  when 
in  a  similar  fracture,  pressure  is  made  on  the  rotula. 
The  fore-arm  is  almost  constantly  in  a  state  of  pro- 
nation. When  we  take  hold  of  one  of  the  condyls 
in  each  hand,  and  eixleavour  to  make  them  move  in 
opposite  directions,  they  can  be  brought  alternately 
forward  or  backward :  and,  if  tlieir  surfaces  touch, 
a  manifest  crepitation  is  heard, 

6.  In  the  second  case  (4),  the  condyls  cannot  be 
so  easily  separated  from  each  other;  but  it  is  alv/ays 
practicable  by  taking  hold  of  that  one  which  is  divided 
from  the  body  of  the  bone,  and  moving  it  from  before 
backward,  to  produce  a  crepitation,  which  is  a  sufii- 


I  92 

cient  proof  that  a  fracture  exists.  In  a  case  where  the 
external  condyl  was  alone  separated,  Desault  found 
the  limb  in  a  constant  state  of  supination,  a  position 
to  be  attributed,  without  doubt,  to  the  muscles  attach- 
ed to  this  condyl. 

7.  An  acute  pain,  the  almost  inevitable  effect  of 
the  flexion  or  extension  of  the  fore-arm,  the  habitual 
semi-flexion  of  the  limb,  a  tumefaction  of  it  some- 
times supervening,  and  a  swelling  more  or  less  con- 
siderable, around  the  joint,  are  symptoms  which  ac- 
company both  modes  of  division  (3  and  4).  The 
fracture  may  further  be  rendered  complicated  by 
means  of  wounds,  splinters,  &c.  when  the  blow  has 
been  very  severe,  or  when  a  pointed  fragment  has 
made  its  way  through  the  sun'ounding  soft  parts,  &c^ 

§  II. 

OF   THE   PROGNOSIS. 

8.  The  preceding  assemblage  of  signs,  leaves  in 
general  but  little  doubt  on  the  subject  of  the  diagno- 
sis; but  is  the  establishment  of  a  solid  prognosis 
attended  with  the  same  facility  ? 

If  authors  be  consulted,  they  will  be  all  found  to 
agree,  in  considering  the  communication  of  fractures 
with  a  joint  as  a  complication  of  a  very  serious  na- 
ture. A  swelling  of  the  adjacent  parts,  their  inflam- 
mation, a  continuance  of  the  pains  after  the  reduction, 
extensive  abscesses,  a  gangrene  even  of  the  soft  parts, 
and  a  caries  of  the  bones ;  such,  according  to  these 
authors,  are  the  almost  inevitable  consequences  of 
th^se  kinds  of  fractures^  of  which  an  anchylosis  ia 


93 

the  most  favourable  termination  that  can  be  expected. 
Petit,  Heister,  and  Duverney,  do  not  describe  the 
evils  that  accompany  these  accidents.  Pai'e,  in  speak- 
ing of  them,  says,  "  In  such  cases,  the  violence  done 
to  the  tendons  generally  gives  rise  to  great  inflamma- 
tion. 

9.  From  whence  can  arise  these  exaggerated 
fears  ?  Can  it  be,  as  is  pretended,  the  mere  commu- 
nication of  the  fracture  with  a  joint,  that  is  productive 
of  such  serious  affections?  What  relation,  then,  can 
reason  discover  between  the  cause  and  the  effect? 
Does  not  experience  answer  in  other  cases,  in  a 
manner  that  admits  of  no  reply,  when  it  furnishes  us 
with  the  analogy  of  fractures  of  the  rotula,  the  ole- 
cranon. Sec? 

Modern  researches  have  entirely  abolished  the 
ancient  theory  of  an  effusion  of  callus  into  the  joint, 
and  with  it  one  of  the  principal  causes  assigned  by 
writers  for  the  accidents  and  evils  which  they  so 
much  dreaded. 

The  admission  of  air  into  an  articular  cavity, 
would  be,  without  doubt,  in  such  cases,  a  considera- 
tion of  more  weight ;  but  this  does  not  occur  except 
in  fractures  accompanied  with  wounds,  and  yet  all 
those  in  the  vicinity  of  joints,  whether  compound  of 
not,  are  regarded  as  extremely  dangerous.  Besides, 
observation  has  oftentimes  proven  to  Desault,  that 
even  the  contact  of  air  is  not  so  dangerous  as  it  has 
been  commonly  supposed,  and  many  instances  oc- 
curred to  him  in  his  practice,  where,  notwithstanding 
such  a  complication,  a  perfect  cure  was  obtained. 


94 

10.  It  is,  then,  to  the  want  of  a  skilful  mode  of 
treatment,  and  to  the  irritation  experienced  in  the 
parts,  in  consequence  of  an  ill-constructed  apparatus 
being  applied  to  them,  that  the  accidents  formerly- 
mentioned  (8)  ought  to  be  attiibuted.  Such  acci- 
dents never  occurred  to  Desault,  in  any  of  the  nume- 
rous cases  that  fell  under  his  care.  It  is  thus  that  in 
the  fracture  of  the  neck  of  the  os  femoris,  the  insuf- 
ficiency of  the  means,  is  oftentimes  productive  of 
unfavourable  results. 


III. 


OF   THE   REDUCTION,   AND   THE   MEANS   OF   MAIN- 
TAINING  IT. 

11.  The  displacement  here  is,  in  general,  incon- 
siderable, because,  being  drawn  in  contrary  direc- 
tions, by  the  muscles  of  the  arm  and  fore-arm,  the 
condyls  separated  from  the  bone  remain  stationary 
between  these  two  forces.  A  fall,  a  percussion,  or 
some  other  external  cause,  can  alone  produce  a  dis- 
placement, by  communicating  some  degree  of  mo- 
tion to  the  fragments.  Nov/,  from  what  was  formerly 
said  (5  &  6),  the  condyls  may,  under  such  an  impulse, 
move  either  forward  or  backward,  or  else  may  sepa- 
rate from  each  other,  leaving  between  them  an  inter- 
mediate void.  Hence  tlie  apparatus  ought  to  oppose 
to  them  a  resistance  in  diese  four  directions,  namely, 
inward,  outward,  forward,  and  backward ;  a  resist- 
ance which  it  will  be  easy  to  make,  by  means  of  four 
splints,  placed  in  these  directions,  and  properly  re- 
tained by  a  roller.  The  two  lateral  splints,  are  paiti- 


95 

cularly  necessaiy,  when  the  condyls  are  both  separated 
from  the  body  of  the  bone,  and  divided  from  each 
other  (3).  If  one  of  them  be  still  attached  to  the  hu- 
merus (4),  a  splint  on  that  side  becomes  less  useful. 

12.  It  is  needless  for  the  apparatus  to  extend  as 
high  up  as  in  a  fracture  of  the  arm.  What  effect,  in 
sustaining  the  fragments,  would  casts  of  a  roller  have, 
when  applied  to  the  body  of  the  bone,  above  the  place 
of  division?  Their  only  advantage  would  consist  in 
compressing  the  brachial  and  triceps  muscles,  and  in 
that  way  preventing  their  action. 

On  the  other  hand,  the  roller  must  be  continued 
along  the  fore-arm,  in  order  that  the  elbow  joint  may 
correspond,  according  to  the  judicious  precept  of 
Paul  of  Egina,  to  the  middle  of  the  bandage,  which 
is  in  general  more  compact  and  solid,  in  the  middle 
than  in  any  other  part,  and  also,  that  a  slight  com- 
pression may  be  thus  made  on  the  muscles  attached 
to  the  condyls. 

13.  The  pieces  which  compose  the  appai'atus,  are 
1st,  A  roller  five  or  six  yai^ds  long,  and  three  inches 
broad,  made  of  soft  linen  or  muslin,  and  rolled  up  in 
a  ball.  2dly,  Four  splints  (11),  two  of  them  flexible 
in  the  middle,  in  order  that  they  may  bend  to  fit  the 
fold  of  the  arm,  and  the  elbow,  and  the  other  two  very 
strong  and  inflexible,  intended  to  be  applied  at  the  two 
sides. 

14.  Eveiy  thing  being  arranged,  the  reduction  is 
effected  in  the  following  manner.  One  assistant  is 
directed  to  make  extension  at  the  upper  part  of  the 
arm,  which  he  grasps  with  both  his  hands;  another 
makes  extension  on  the  fore-arm  half-bent,  which  he 


96 

uses  as  a  lever  of  the  second  kind,*  where  one  of  his 
hands,  being  placed  under  tlie  wrist,  forms  a  fulcrum, 
while  the  other  applied  towards  the  fold  of  the  arm, 
represents  the  power.  The  surgeon,  in  the  mean  time 
brings  the  condyls  together,  adjusts  their  level  and 
apposition,  both  between  themselves,  and  with  the 
body  of  the  bone,  and  then  proceeds  to  the  application 
of  the  apparatus,  the  limb  being  still  kept  in  a  half- 
bent  position,  as  was  long  since  recommended  in 
such  cases  by  Paul  of  Egina.  '■'■Si  in  'oicinia  cubiti 
brachium  fr actum  est,  etiam  ipse  cubitus  deligandus,, 
angulari  Jigura  seroata.'''' 

15.  The  roller  (13),  wet  with  vegeto- mineral 
water,  which  facilitates  its  application,  and  prevents 
the  swelling  of  the  part,  is  fastened  by  one  of  its 
ends,  about  two-thirds  down  the  fore-arm,  and  con- 
tinued upv/ards  by  oblique  and  reverse  casts,  to  the 
joint.  The  surgeon  then  passes  a  cast  of  the  roller 
from  the  anterior  and  superior  part  of  the  fore -arm, 
to  the  posterior  and  inferior  part  of  the  arm  (humerus), 
redescends  by  an  oblique  cast  irom  the  other  side, 
over  the  fore-arm,  and  returning  along  the  first  track, 
makes  a  number  of  casts  in  the  form  of  the  figure  of 
8,  round  the  joint,  which  he  next  covers  by  circulai* 
casts,  applied  so  close  to  each  other,  as  to  leave  no 
opening  between  them ;  he  then  proceeds  upwai^ds  by 
oblique  casts,  as  at  the  first,  to  the  middle  pait  of 
the  arm  (humerus),  when  the  roller  is  given  into  the 
hand  of  an  assistant. 

*  In  this  form  of  lever,  the  power  is  applied  between  the 
fulcrum  and  the  weight  to  be  moved,  or  the  resistance  to  be 
overcome.  Trans. 


91 

The  first  of  the  sphnts  (13)  is  now  placed  anteri- 
orly  on  the  fore -arm  and  arm,  and,  if  it  does  not  bend, 
in  such  a  manner,  as  to  accommodate  itself  to  the 
fold  of  the  arm,  the  vacant  space  beneath  it  is  filled 
up  with  compresses,  laid  on  top  of  each  other,  so  as 
to  make  its  compression  uniform  throughout.  The 
second,  being  applied  on  the  posterior  side  part  of 
the  arm,  moulds  itself  to  the  projection  of  the  elbow, 
while  the  other  two  occupy  the  sides.  These  are  se- 
cured below  by  an  assistant,  while  the  surgeon  resu- 
ming the  roller,  which  he  had  just  given  out  of  his 
hand,  fixes  them  firmly  by  circular  casts  descending 
along  the  arm  and  fore-arm. 

The  limb  is  then  laid  on  a  pillow,  so  disposed 
that  the  hand  may  be  raised  higher  than  the  elbow, 
in  order  to  prevent  the  subsequent  swelling,  which  is 
oftentimes  produced  by  the  firacture,  as  has  been  al- 
ready mentioned  (7). 

16.  The  eifect  of  this  bandage  is  simple,  and  has 
a  particular  relation  to  those  directions  and  causes,  in 
and  by  which,  displacements  might  occur.  The  two 
lateral  splints  prevent  the  separation  of  the  condyls 
fi'om  each  other;  the  anterior  and  posterior  ones  pre- 
vent them  from  moving  backward  or  forward ;  the 
muscles  are  compressed ;  the  motion  of  the  joint  is 
prevented ;  and,  in  common,  no  great  length  of  time 
is  necessary  for  the  reunion  of  the  bone. 

As  soon  as  this  is  accomplished,  it  is  of  impor- 
tance to  move  the  limb  in  every  direction,  to  pre- 
vent that  stiffiiess,  which  is  so  commonly  the  conse- 
quence of  fractures  situated  in  the  neighbourhood 
of  joints.    The  following  case,  drawn  up  by  Le- 

14 


9^ 

geuUe,  will  furnish  the  reader  with  a  detailed  account 
of  the  treatment  pursued,  in  such  accidents,  by  De^ 
sault. 

Case  I.  Joseph  Kisler,  an  ostler,  aged  forty- 
one,  fell  from  a  height  of  thirty  feet,  on  the  left  side, 
his  arm  being  undermost,  and  fractured  the  lower 
end  of  the  humerus.  A  surgeon  gave  him  immedi- 
ate assistance,  and,  at  the  expiration  of  two  days,  he 
was  caiTied  to  the  Hotel-Dieu. 

From  the  signs  formerly  mentioned  (5  and  7),  De- 
sault  discovered  a  fracture,  consisting  in  a  separation 
of  the  condyls  from  each  other,  by  a  longitudinal  di- 
vision, and  from  the  body  of  the  bone,  by  a  transverse 
one.  The  usual  apparatus  (16)  was  applied,  and, 
from  a  state  of  extreme  anguish,  which  he  had  till 
now  suffered,  the  patient  experienced  immediate 
relief. 

In  the  mean  time,  a  considerable  swelling  around 
the  joint,  pointed  out  the  necessity  of  blood-letting, 
a  low  diet,  and  other  antiphlogistic  remedies.  These 
were  immediately  liad  recourse  to,  and  the  limb  was 
placed  in  the  proper  position  (16). 

Not^vithstanding  these  precautions,  the  tumefac- 
tion and  redness  were  increased  on  the  following  day. 
The  bandage  was  applied  anew,  and  wet  from  time 
to  time  with  vegeto-mineral  water. 

On  the  following  days,  pain  less  severe,  the  ban- 
dage kept  constantly  wet  with  the  same  fluid. 

Eighth  day,  the  swelling  almost  gone  ;  the  appa- 
ratus, being  loosened,  was  again  reapplied. 

Fifteenth  day,  the  fragments,  being  examined, 
were  found  in  regulai'  contact,  and  already  united  by 


99 

a  substance  of  considerable  firmness ;  the  strictness 
pf  regimen  gradually  relaxed ;  solid  food  taken  in 
small  quantity. 

Nothing  new  till  the  twenty- second  day,  when 
the  splints  were  laid  aside,  having  become  useless, 
in  consequence  of  the  rapid  progress  of  reunion : 
from  this  time  till  the  completion  of  the  cure,  no- 
thing was  used  but  the  simple  roller. 

On  the  twenty-fourth  day,  gentle  flexion  and  ex- 
tension of  the  arm  and  fore -arm  were  for  a  short  time 
performed;  these  movements  were  attended  with 
acute  pain,  notwithstanding  which,  the  fortitude  of 
the  patient  enabled  him  to  persevere  in  them. 

Thirtieth  day,  no  pain  accompanies  the  m.ove- 
ments  of  the  arm :  the  range  of  these  movements 
visibly  increased ;  the  roller  laid  aside ;  from  this 
time  the  range  of  motion  increases  rapidly. 

On  the  thirty- seventh  day,  the  patient  w^as  dis- 
charged perfectly  cured,  and  free  from  every  vestige 
of  his  disease,  except  a  trifling  stiffness,  which  was 
doubtless  soon  removed  by  the  motions  of  the  joint. 

17.  When  wounds,  splinters,  or  severe  contu- 
sions, render  these  kinds  of  fractures  more  compli- 
cated, an  inflammation  occurring  on  the  articular  sm'- 
faces,  may  cause  them  to  unite  together,  and  by  that 
means  give  rise  to  an  anchylosis.  But  this  accident, 
inevitable  in  such  a  case,  according  to  WTiters,  does 
not  always  occur,  provided  nature  be  assisted,  by  a 
judicious  mode  of  treatment,  in  her  attempt  to  re- 
unite the  broken  bone.  Desault  has  established  this 
truth,  in  many  instances.  Here,  as  in  other  joints, 
he  has  oftentimes  obtained  a  complete  cure,  without 


100 

the  loss  of  motion,  although  the  part  had  sustained 
the  greatest  violence.  Incisions,  easily  made,  the  ex- 
traction of  splinters,  a  frequent  renewal  of  dressings, 
a  most  vigilant  care  to  prevent  all  jarring  of  the  limb, 
and  consequently  all  derangement  of  the  contact  of 
the  fragments,  an  assemblage  or  combination  of  those 
minute  attentions,  which  art  cannot  teach,  which  ge- 
nius suggests,  and  which  characterize  the  true  sur- 
geon ;  a  precaution  (not  to  be  dispensed  with)  to 
make  the  limb  perform  motions,  gentle  at  first,  but 
gradually  increased  afterwards,  when  the  adhesion  of 
the  parts  has  acquired  sufficient  solidity  to  admit  of 
it ;  such  are,  in  general,  the  steps  and  circumstances 
constituting  the  bases  of  that  treatment,  requisite  in 
these  complicated  fractures,  which,  like  all  others, 
appear,  in  each  case,  to  assume  a  new  aspect,  and 
to  present  different  indications. 

C  A  SE  II.  A  person,  carrying  a  heavy  burden,  fell 
with  his  elbow  on  a  sharp  corner  of  a  bar  of  iron. 
The  external  condyl  was  broken,  being  separated 
from  the  body  of  the  bone,  by  an  oblique  division 
running  into  the  joint.  Anteriorly,  a  large  contusion; 
posteriorly,  a  transverse  wound;  on  the  outside,  the 
end  of  the  condyl  projecting  through  the  soft  parts, 
which  it  had  lacerated :  such  were  the  complications 
of  a  fracture,  for  which  the  patient  was  admitted  into 
the  Hotel-Dieu,  on  the  seventh  day  of  January,  1794. 

On  examining  the  state  of  the  parts,  Desault  dis- 
covered, in  the  transverse  wound,  two  splinters  which 
vv'hen  extracted,  gave  vent  to  an  effusion  of  blood. 
He  reduced,  instead  of  cutting  it  off,  as  authors  have 
advised,  the  end  of  the  separated  condyl,  applied  a 


101 

bandage  of  of  strips,*  and,  to  prevent  accidents,  or- 
dered a  strict  diet,  copious  blood-letting,  and  dilut- 
ing drinks. 

Compresses  wet  with  vegeto-mineral  water,  kept 
the  apparatus  constantly  moist. 

On  the  day  following,  the  dressing  was  renewed 
superficially ;  severe  pains  in  the  part ;  abated  towards 
evening;  almost  gone  next  day;  low  diet  continued. 

Fourth  day,  pains  returned ;  an  incipient  swell- 
ing around  the  joint;    more  blood  drawn. 

Sixth  day,  considerably  better;  all  the  apparatus 
renewed ;  suppuration  beginning  to  appear. 

Tenth  day,  a  small  abscess  on  the  external  condyl 
opened,  and  a  splinter  extracted  posteriorly. 

Fifteenth  day,  the  parts  assume  a  flattering  aspect; 
suppuration  favourable;  fragments  in  contact;  from 
this  time  the  dressings  are  less  frequent. 

Twentieth  day,  a  bilious  diathesis ;  edges  of  the 
wounds  livid;  loss  of  appetite;  nausea;  vomiting; 
an  emetic  is  administered. 

*  (Bandage  a  bandalettes.)  This  is  a  most  convenient  form 
of  bandage,  in  fractures  of  the  upper  or  lower  exti^emities.  It 
is  composed  of  strips  of  soft  linen  or  muslin,  from  two  to  thi'ee 
inches  wide,  and  of  a  length  accommodated  to  the  size  of  the 
limb,  on  which  they  are  to  be  applied.  These  strips  are  not 
sewed  together,  but  merely  laid  along  side  of  each  other,  or  ra- 
ther spread  in  such  a  way  that  their  adjoining  edges  may  over- 
lap a  little.  Being  thus  arranged,  on  the  bed  or  matrass,  where 
the  patient  is  to  lie,  the  broken  limb  is  placed  on  them,  when 
the  surgeon,  taking  them,  one  by  one,  folds  them  round  it,  so  as 
to  form  a  very  perfect  and  neat  covering.  The  number  of  these 
strips  must  be  regulated  by  the  extent  of  the  limb,  or,  at  least, 
of  that  portion  of  the  limb,  which  they  are  intended  to  cover. 

Trans. 


102 

Thirtieth  day,  unfavourable  appearances  gonej 
reunion  commencing;  wounds  visibly  healing.  For- 
tieth day,  all  external  injuries  healed,  except  the  one 
situated  anteriorly ;  callus  already  very  firm ;  gentle 
motions  performed  with  the  limb,  which  is  still  sur- 
rounded by  the  apparatus. 

Forty- seventh  day,  the  apparatus  become  useless; 
motions  gradually  increased;  articulation  aheady 
tolerably  free.  Fifty-seventh  day,  bilious  diathesis 
returned;  low  diet  and  evacuants.  Sixty-fifth  day, 
the  patient  discharged  from  the  hospital ;  consolida- 
tion perfect;  wounds  entirely  healed;  motions  of 
extension  still  difficult  to  be  performed  in  their  full 
extent,  but  are  recovered  in  a  great  measure,  and 
will  doubtless,  in  a  short  time,  be  completely  re-esta- 
blished, provided  the  same  mode  of  treatment  be 
continued. 


MEMOIR  VII. 

ON   THE    LUXATION    OF   THE    HUMERUS. 

GENERAL   REMARKS   ON   THE   JOINTS,    AND   ON 
THAT  OF  THE  HUMERUS  IN  PARTICULAR. 

1.  Nature,  who,  according  to  the  wants  of  dif- 
ferent species  of  animals,  has  vai'ied  the  number  of 
their  articulations,  knows  also  how  to  vary  their 
structure,  according  to  the  uses  of  the  different  parts 
of  their  bodies.  With  great  mobility,  she  has  some- 
times connected  great  solidity  and  strength,  as  is  the 


103 

case  in  the  vertebral  column ;  in  other  instances,  parts 
very  solid  and  compact,  are  capable  of  performing 
but  feeble  motions,  as  the  carpus,  the  tarsus,  Sec. 
And,  lastly,  other  paits,  again,  capable  of  great  mo- 
tion, possess  so  little  solidity  and  firmness  as  to  be 
easily  deranged  by  the  action  of  external  bodies.. 
Such,  in  man,  is  the  articulation  of  the  humerus  with 
the  scapula,  of  the  sternum  with  the  clavicle,  &c. 

2.  Hence  there  exist  three  classes  of  articulations, 
very  different  from  each  other.  To  the  last,  as  enu- 
merated above,  belongs,  in  a  particular  manner,  the 
history  of  luxations,  and,  in  this,  as  the  solidity  varies, 
thefi^equency  of  dislocations  is  equally  various ;  no  lux- 
ation occurs  more  frequently  than  that  of  the  hume- 
rus ;  indeed,  m  a  comparative  catalogue  of  accidents 
of  this  kind,  it  alone  has,  during  certain  years,  occur- 
red oftener,  in  the  Hotel-Dieu,  than  that  of  all  the 
other  bones,  taken  collectively. 

3.  Every  thing  seems  to  favour  the  escape  of  this 
bone  from  its  natural  cavity.  1st,  On  the  part  of  the 
articulating  surfaces,  a  cavity  somewhat  oval  and  very 
shallow,  aided  by  a  slight  cartilaginous  ring,  receives 
a  half- spherical  head,  twice  its  own  diameter  fi-om 
above  downwards,  and  three  times  as  large  from  be- 
fore backwards.  2dly,  On  the  part  of  the  ligaments, 
this  articulation  is  strengthened  by  only  a  simple 
capsule.  This  capsule  is  thin  and  weak  on  its  lower 
side,  a  direction  in  which  there  is  nothing  to  prevent 
a  luxation,  while  it  is  thicker  on  its  upper  side,  wherc 
the  acromion  and  coracoid  apophyses,  and  a  strong 
ligament,  present  an  obstacle  almost  insurmountable. 
3dly,  As  far  as  respects  the  muscles  and  the  motions 


104 

of  the  joint,  strong  and  numerous  bundles  of  fibres 
surrounding  the  articulating  surfaces,  communicate 
to  them  motions  easily  performed  in  every  direction, 
and  which,  by  pushing  the  head  of  the  humerus 
against  the  different  parts  of  the  capsule,  distend  it, 
predispose  it  to  laceration,  and  indeed  even  rupture 
it,  when  the  quantum  of  their  force  is  superior  to  its 
resistance.  4thly,  As  far  as  relates  to  external  bodies, 
what  bone  is  more  exposed  to  their  action  than  this, 
particularly  among  that  class  of  persons,  engaged,  for 
a  livelihood,  in  hai'd  labour? 

4.  Subject  to  the  influence  of  these  different  pre- 
disposing causes,  the  humerus  would  be  constantly 
liable  to  luxations,  did  not  the  scapula,  moveable  like 
itself,  furnish  it,  by  accompanying  its  motions,  with 
a  point  of  support,  differently  disposed,  according  to 
the  different  position  of  its  superior  extremity ;  so 
that,  to  this  two-fold  mobility  of  the  articulating  sur- 
faces, is  to  be  attributed,  in  a  great  measure,  the 
stability  of  their  connexion. 

OF  THE  KINDS  OF  THIS  LUXATION, 

5,  The  upper  articulation  of  the  humerus,  though 
predisposed,  in  general,  to  luxations,  is  not  equally 
so  in  every  direction.  There  is  a  point  at  which  lux- 
ation cannot  take  place.  There  are  others,  where, 
though  possible,  this  accident  has  never  been  obser- 
ved. It  is  necessary,  therefore,  before  examining 
the  mechanism  of  this  luxation,  to  mention  with  pre- 
cision, the  directions  in  which  it  may  occur.  On  this 


105 

point,  writers  have  differed  in  a  very  singular  man- 
ner. Sometimes,  to  express  the  same  thing,  they  have 
used  a  different  language ;  and,  at  other  times,  have, 
by  the  same  words,  expressed  things  widely  different. 
Always  agreeing  as  to  certain  modes  of  dislocation, 
they  have  been  divided  as  toothers;  while,  in  the 
midst  of  those  contrarieties,  the  surgeon  being  em- 
barrassed, is  at  a  loss  on  what  ground  to  found  his 
practice. 

6.  The  ancients,  knowing  but  little  of  the  natural 
relation  of  the  parts  surrounding  the  joint,  were  ig- 
norant of  the  accidental  ones,  which  these  several 
parts  assume,  in  the  case  now  under  our  considera- 
sion.  Hence,  without  doubt,  arises  the  confusion, 
of  their  opinions  on  the  subject. 

Many  admitted  of  four  kinds  of  luxations;  a 
great  number  acknowledged  only  three;  some  sub- 
scribed to  but  two;  while  others  believed  in  the 
possibility  of  none  but  one. 

7.  The  first  divided  differently  the  directions  in 
which  the  bone  might  be  luxated.  Some  contended 
for  luxations  upward,  doMaiward,  forward,  and  back- 
ward; and  such  was  the  opinion  of  the  first  Greek 
physicians,  predecessors  to  the  father  of  medicine, 
who  has  transmitted  the  opinion  to  u^  accompanied 
with  a  demonstration  of  its  fallacy.  Others  have  divided 
them  into  those  that  take  place  downward,  upwai'd, 
outward,  and  forward.  This  division  is  adopted  by 
Galen,  who  yet  produces  only  an  example  of  a  for- 
ward luxation,  and  does  not  give  us  to  understand 
what  he  means  by  a  luxation  upward  and  inward. 

15 


ma 


8.  The  second  distinguished  the  modes  of  this 
luxation,  sometimes  into  downwai'd,  forward,  and 
backward;  as  was  the  case  with  Oribazes;  at  other 
times,  into  downward,  outward,  and  inward,  accord- 
ing to  the  opmion  of  Paul  of  Egina,  who,  no  doubt, 
adopted  exactly  the  preceding  divison,  expressing  it 
only  in  different  words;  sometimes  into  downward, 
forward,  and  up\T'ard;  such  was  the  sentiment  of  Al- 
bucasis,  who,  notwithstanding,  considered  a  luxation 
upward,  as  a  very  difficult,  and  yevy  rare  occurrence. 

9.  The  third  were  of  opinion,  that,  in  undergo- 
ing a  displacement,  the  head  of  the  humerus  could 
be  earned  only  downward,  under  the  aiTQ-pit,  which 
is  the  most  common  direction,  or  forwai'd,  a  course 
which  it  takes  more  rarely.  Celsus  is  almost  the  only  ^ 
•writer  who  has  contended  for  this  division,  "  Hu- 
7nerus,  says  he,  modo  in  alam  excidity  modo  in  par- 
tem priorem.'''' 

10.  Lastly,  The  fourth  believe,  with  Hippocrates^, 
in  none  but  a  displacement  downwards,  the  only 
one  which  that  physician  has  met  with  in  his  prac- 
tice.  "  At  liero  humerus^  inferior  em  in  partem  exci- 
dit;  aliajn  in  partem  excidere  non  audivi.'''' 

11.  The  moderns,  in  borrowing  from  the  ancients 
their  divisions  of  luxations,  did  not,  like  them,  de- 
termine a  priori  and  in  a  vague  manner,  the  precise 
spot  and  direction  of  displacement;  but  ascertained 
these  points  by  subsequent  observation,  wAih.  more 
precision,  in  proportion  as  a  knowledge  of  anatomy 
shed  light  on  them.  They  also  paid  particular  atten- 
tion to  the  essential  difference  betv/een  primitive  and 
consectiti-s'e  luxations. 


107 

12.  Petit  adttiitted  of  four  kinds  of  luxations,  1st, 
downwai'd,  on  the  edg-e  of  the  scapula :  this  is  a  very 
rare  occurence :  2dly,  outward,  under  the  spine  of 
tliat  bone,  a  kind  very  difficult  to  be  primitively  pro- 
duced. 3dly,  inwards,  under  the  hollow  of  the  aim- 
pit.  4thly,  forward,  between  the  corocoid  apophysis 
and  the  clavicle.  With  this  illustrious  practitioner, 
Heister  acknowledged  four  kinds  of  displacements; 
but,  here  again,  Vv^as  a  new  variety,  both  in  expres- 
sion, and  in  meaning.  The  one  says,  downvi^ard, 
under  the  arm-pit,  the  other  forwai'd,  under  the  pec- 
toralis  major;  the  one,  backv/ard,  under  the  sca- 
pula, the  other  outward,  under  its  spine.  Accord- 
ing to  Duverney,  luxations  are  never  primitively  in 
any  other  direction  than  downwai'd ;  the  others  being 
only  the  subsequent  effect  of  muscular  action. 

13.  In  the  midst  of  these  very  complicated  modes 
of  treating  a  very  simple  subject,  it  is  necessarj^,  first, 
in  order  to  acquire  definite  ideas,  to  divide  luxations 
of  the  humerus  into  primitive,  which  are  the  imme- 
diate effect  of  external  violence,  and  consecutive, 
which  succeed  the  primitive,  through  the  influence 
of  causes  which  I  am  about  to  consider. 

Let  us  suppose  four  lines  to  inscribe,  in  form  of 
a  parallelogram,  the  oval  surface  of  the  glenoid  cavity, 
one  representing  the  superior  edge,  another  the  inferi- 
or, a  thu'd  the  internal,  and  the  fourth  the  external. 

14.  It  is  evident  that  the  head  of  the  humerus 
cannot  be  displaced  towards  the  superior  edge.  In  that 
direction,  must  be  encountered,  the  acromion  and 
corocoid  apophyses,  the  strong  ligament  passing  be- 
tween them,  the  tendons  of  the  triceps  and  supra- 


108 

spinatus  muscles,  and  the  fleshy  mass  of  the  deltoid; 
all  which,  taken  together,  constitute  an  insurmount- 
able obstacle  to  the  escape  of  die  head  of  the  bone 
upwards.  Besides,  wliat  power  could  carry  it  up- 
wards? In  order  that  this  kind  of  luxation  might  take 
place,  it  v/ould  be  necessary,  that  the  head  of  the 
bone  should  be  carried  outwards  at  the  same  time, 
as  well  as  upwards,  a  circumstance  which  is  im- 
possible, because  the  trunk  prevents  the  lower  extre- 
mity (the  elbow)  from  being  directed  sufliciently 
inward  to  produce  such  an  effect. 

15.  On  the  contrary,  in  other  directions,  but  veiy 
little  resistance  is  to  be  met  with.  Towards  the  infe- 
rior edge  of  the  cavity,  the  long  portion  of  the  triceps; 
the  tendon  of  the  subscapularis,  towards  the  internal 
edge ;  and  towards  the  external  edge,  the  tendons  of 
the  infra-spinatus,  and  teres  minor,  yield  with  ease 
to  a  force  directed  against  them,  and  permit  the  occur- 
rence of  primitive  luxations,  downward,  inward,  and 
outward.  Downward,  between  the  tendon  of  the  long 
portion  of  the  triceps,and  that  of  the  subscapularis ;  in- 
ward, between  the  subscapulary  muscle  and  fossa;* 
and  outward,  between  the  fossa  infra-spinatus  and  the 
muscle  of  the  same  name.  These  modes  of  displace- 
ment are  not  alike  frequent,  as  will  be  mentioned  pre- 
sently. 

16.  Having  escaped  from  its  cavit}",  and  being 
primitively  placed  in  one  of  these  tliree  situations,  the 

*  ( La  fosse  sous-scafiulaire ) .  I  know  of  no  English  anato- 
mical term  for  this.  I  therefore  translate  it  literally.  The  same 
is  true  with  respect  to  '■^Jossa  sozis-ejiineuse"  translated  here» 
fossa  infra-spinata.  Trans. 


109 

head  of  the  humerus  oftentimes  changes  its  position. 
Then,  to  a  primitive  luxation  downward  or  inward, 
succeeds  a  consecutive  or  secondary  one ;  but  never 
to  a  luxation  in  an  outward  direction,  if  suxih  ever 
occur,  because  the  spine  of  the  scapula  forms  an  ob- 
stacle to  it. 

A  secondary  luxation  inward,  may  succeed  a  pri- 
mitive one  downwai'd ;  there  is  nothing  to  oppose  the 
head  of  the  humerus  in  the  course  it  takes,  to  enter 
between  the  subscapulary  muscle  and  fossa.  If,  on 
the  other  hand,  it  be  disposed  to  pass  to  the  external 
side,  the  tendon  of  the  triceps  opposes  it ;  and,  not- 
withstanding what  Petit  has  advanced,  there  is  no 
secondary  luxation  in  that  direction. 

17.  It  sometimes  happens,  that,  having  escaped 
either  from  the  internal  part,  or  from  the  inferior  part 
of  the  capsule,  the  head  passes  behind  the  clavicle, 
and  forms  there  a  secondary  luxation  upwards,  as 
has  been  observed  by  Ambrose  Pare,  and  by 
Gallien,  and  of  which  an  example  or  specimen  was 
preserved  in  the  cabinet  of  Desault.  But,  here,  the 
secondary  displacement  must  take  place  in  a  slow 
manner,  and  when  it  has  taken  place,  art  can  seldom 
remove  it,  on  account  of  the  strong  adhesions  formed 
by  the  bony  surfaces.  Thus,  in  the  example  men- 
tioned, there  was  a  new  cavity  formed  behind  the 
clavicle,  and  the  humerus  adhered  to  the  surround- 
ing parts  by  a  kind  of  new  ligaments. 

18.  It  appears  from  what  has  been  said,  that  the 
humerus  is  subject  to  four  different  kinds  of  displace- 
ment. 1st,  Dovinnjoard :  2dly,  outward,  in  both  of 
which  directions  the  luxation  is  always  primitive  ; 


110 

Sdiy,  inwards,  where  it  is  sometimes  primitive,  and 
sometimes  consecutive ;  4thly,  upwards,  where  it 
can  never  be  otherwise  than  consecutive. 

The  second  and  fourth  are  very  rare  occun*ences, 
and  bear  so  small  a  proportion  to  the  others,  that  the 
latter  alone  ought  to  command  the  attention  of  the 
practitioner. 

\  III. 

OF   THE   CAUSES   AND    THE   MECHANISM. 

19.  The  causes  and  the  mechanism  of  luxations 
of  the  humerus,  varj^  according  as  the  displacement 
is  primitive  or  consecutive. 

The  action  of  external  bodies,  directed  against 
the  ai'm,  but  more  particulai'ly  falls,  where  tliis  part 
strikes  forcibly  against  a  resisting  body,  give  rise  in 
general  to  primitive  luxations,  and,  according  as  it  is 
differently  situated  at  the  time  of  the  fall,  the  hume- 
rus determines,  by  its  position,  the  different  kinds. 

20.  If  it  be  separated  from  the  trunk,  without  be- 
ing can'ied  either  before  or  behind  it,  if  the  elbow  be 
elevated,  and  the  fall  be  on  the  side,  the  weight  of 
the  body,  being  almost  entirely  supported  by  this 
bone,  pushes  its  upper  extremity  do^viiward,  dis- 
tends the  inferior  part  of  the  capsule,  lacerates  it,  and 
produces  a  luxation  do'wn^vard,  in  which  it  may  even 
be  favoured  by  the  action  of  the  pectoralis  major,  the 
latissimus  dorsi,  and  the  teres  major,  as  has  been  ju- 
diciously observed  by  Fabre.  In  such  a  case,  these 
muscles,  involmitarily  contracting  to  support  the 
trunk,  act  like  the  power  or  force  in  a  lever  of  the 
second  kind,  the  resistance  to  which  is  formed  by 


Ill 

the  head  of  the  bone,  which  they  di'aw  downward, 
while  the  lower  extremity  of  the  humerus,  resting 
on  the  ground,  constitutes  the  fulcrum.  Some  au- 
thors even  regard,  as  an  immediate  cause  of  luxation^ 
the  powerful  contraction  of  the  dehoid  muscle,  whicb 
depresses  the  head  of  the  bone,  and  forces  it  through, 
the  lower  side  of  the  capsule,  a  mode  of  displacement, 
the  existence  of  which  observation  incontestibly  esta- 
blishes. The  case  of  a  scrivener,  so  often  cited,  is 
well  known,  who  in  liftmg  a  book  of  records  hixated 
his  humerus  in  a  do"\niward  direction. 

21.  The  mechanism  of  a  primitive  luxation  in- 
wards, differs  a  little  from  the  preceding.  The  elbow, 
being  at  once  separated  from  the  trurik,  and  caiTied 
backward,  the  person  falls  :  the  Vv'eiglit  of  the  body 
rests  on  the  humerus ;  the  capsule  is  lacerated  in  its 
fore-part ;  and  a  displacement  in  the  same  direction 
supervenes. 

22.  In  a  luxation  outwards,  the  elbow  is  carried 
jforward,  to^vards  the  opposite  shoulder ;  the  capsule 
being  sti'etched  outwardly,  gives  way  in  that  part, 
fffovided  the  humerus  be  acted  on  by  a  sufficient 
power.  But  what  can  this  power  be  ?  In  a  fall,  the 
arm  being  pushed  against  the  tnmk,  and  stopped  by 
it,  cannot  carry  its  motion  to  a  sufficient  extent  to 
produce  a  laceration  of  the  capsule.  Hence  a  luxa- 
tion outwards  must  be  extremely  rare.  Indeed  no 
instance  of  it  is  to  be  found  in  books  of  surgery. 
Desault,  in  particular,  never  witnessed  it.  Besides, 
when  in  a  fall,  the  arm,  separated  from  the  body,  is 
carried  backward  or  forwai'd,  the  weight  of  the  body 
s^cts  obliquely  on  it,  and  it  is  but  partially  subjected 


112 

to  the  action  of  the  latissimus  dorsi,  the  pectoralis 
major,  and  the  teres  major.  So  that  no  kind  of  luxa- 
tion ought  from  these  considerations,  to  be  very  fre- 
quent, except  that  in  a  doi'^oiward  direction,  where 
the  influence  of  both  causes  is  direct.  Yet  luxation 
inwards  is  common  enough,  and  in  many  instances 
Desault  has  observed  this  primitive  mode  of  displace- 
ment, though  many  modem  authors  doubt  the  fact, 
believing,  with  Hippocrates,  that,  primitively,  all 
luxations  are  downwards. 

23.  It  may  so  happen  that  in  a  primitive  luxation, 
the  capsule  is  only  greatly  stretched,  in  which  case, 
the  articulating  surfaces  are  but  pailially  displaced ; 
but  this  membrane  more  frequently  suffers  a  rupture, 
through  which  the  head  of  the  bone  escapes.  To  this 
phenomenon  v/r iters,  in  general,  have  paid  too  little 
attention,  notwithstanding  the  opening  of  dead  bodies 
has  oftentimes  demonstrated  its  existence  to  practi- 
tioners, particularly  to  Desault,  who  has  given  two 
examples  of  it  modelled  in  wax  ;  one,  of  a  luxation 
inward,  and  the  other  downward,  both  found  in  sub- 
jects that  died  in  the  Hotel-Dieu.  Bell  relates  some 
analogous  facts,  and  another  English  surgeon  has 
also  had  occasion  to  meet  with  them. 

24.  Oftentimes,  in  compound  fractures,  one  of  the 
fragments  passes  through  the  integuments.  In  the 
dislocation  of  the  humerus  something  similar  to  this 
occurs.  The  capsule  is  sufiiciently  lacerated  to  allow 
the  head  to  escape ;  but  the  opening,  being  then  too 
narrow,  forms  around  the  neck  of  the  bone  a  noose  or 
kind  of  collar,  which  prevents  it  from  re-entering  the 
place  which  it  originally  occupied.  Thus,  in  the  frac- 


113 

tures  of  which  I  have  just  spoken,  the  aperture  In  the 
skin  does  not,  at  times,  admit  of  the  reduction  of  the 
fragment,  without  a  previous  dilatation. 

In  this  case,  an  attempt  is  made  to  reduce  the  lux- 
ation :  the  capsule  is  pressed  in  folds  against  the  gle- 
noid .cavity,  and,  interposing  itself  between  it  and  the 
head  of  the  humerus,  renders  fruitless  the  efforts  of 
the  surgeon  who  would  replace  die  bone.  Desault 
was  the  first  who  observed  this  practical  fact,  two  in- 
stances of  which  are  recorded  in  his  journal,  and 
which  has  frequently  since  occurred  in  the  Hotel- 
Dieu.  In  such  a  case,  the  head  is  in  general  extreme- 
ly moveable,  because,  being  entirely  without  the 
capsule,  there  is  nothing  to  impede  its  motion. 

25.  When,  to  a  primitive  luxation  a  consecutive 
one  succeeds,  several  causes  may  concur  in  its  pro- 
duction. If  a  second  fall  happen,  the  arm,  being 
separated  from  the  body,  the  head  of  the  humerus 
having  nothing  to  retain  and  secure  it,  obeys,  with 
great  facility,  the  power  tending  to  displace  it  in  that 
direction,  and  suffers  a  firesh  removal  from  the  bed 
which  it  accidentally  occupies. 

Case  L  A  man  fell  in  descending  a  ladder,  and 
luxated  his  humerus  in  a  downward  direction.  De- 
sault being  immediately  called,  discovered  the  nature 
of  the  disease,  but  deferred  the  reduction  till  evening. 
In  the  interval,  the  patient  w€nt  to  get  into  a  chaise : 
his  foot  slipped,  and  he  fell  a  second  time.  The  pains 
became  more  severe  than  at  the  time  of  the  first  acci- 
dent; and  Desault,  on  his  return,  instead  of  finding, 
as  in  the  morning,  the  head  of  the  humerus  under  the 

16 


114 

hollow  of  the  arm-pit,  discovered  it  to  be  behitid  the 
pectoralis  major. 

26.  Muscular  action  is  one  permanent  cause  of  a 
new  displacement.  Suppose  the  humerus  luxated 
downward,  the  pectoralis  major,  and  the  deltoid  mus- 
cles draw  its  superior  extremity  upward  and  inward, 
which,  offering  to  their  action  but  a  feeble  resistance, 
changes  its  position  and  that  in  a  two-fold  direction. 

27.  The  different  motions  of  the  arm  may  also, 
according  to  their  direction,  produce  the  same  effect. 
Thus  we  have  often  witnessed  a  luxation  inwards 
succeeding  to  a  luxation  do"viaiwards,  in  consequence 
of  unskilful  attempts  to  reduce  it. 

§  IV. 

OF   THE   SIGNS. 

28.  The  diagnosis  of  luxations  of  the  humerus, 
presents  in  general,  but  few  difficulties. 

Whatever  may  be  the  mode  or  seat  of  the  dis- 
placement, there  always  exists,  as  Hippocrates  has 
observed,  a  manifest  depression  under  the  acromion, 
which  exhibits  a  prominence  more  perceptible  than 
in  its  natural  state.  The  motions  of  the  part  are  al- 
most all  accompanied  with  pain ;  the  greater  pai't  of 
them  are  impracticable ;  all  of  them  very  much  con- 
fined. The  arm  cannot  move,  without  a  synchronous 
motion  of  the  shoulder,  because,  the  articulation  be- 
ing no  longer  able  to  exercise  its  functions,  these  two 
parts  constitute,  so  to  spealc,  but  one  body. 

29.  Besides  these  signs,  which  characterize  gene- 
rally everj^  species  of  luxation  of  the  humerus,  each 


115 

species  is  m^ked  by  certain  others  peculiar  to  itself. 
If  the  displacement  be  downward,  the  arm  is  a  little 
longer  than  in  its  natural  state;  it  can  be  moved 
gently  outwards ;  but  an  acute  pain  is  the  inevitable 
consequence  of  moving  it  forward  or  backward. 
The  elbow  is  more  or  less  removed  from  the  axis  of 
the  bod}^  by  the  action  of  the  deltoid,  the  long  por- 
tion of  the  biceps,  and  the  supra- spinatus  muscles, 
which,  being  unnaturally  stretched,  contract  them- 
selves and  tend  to  carry  the  bone  outward.  The  pains 
which  result  from  this  position,  force  the  patient,  in 
order  to  relieve  them,  to  lean  towards  the  affected 
side,  to  keep  the  fore-arm  half-bent,  the  elbow  resting 
on  the  hip,  so  that  the  arm,  finding  a  place  of  support, 
may  be  freed  from  the  painful  movements,  and  from 
the  disagreeable  sensation  produced  by  its  own 
weight.  From  this  attitude  alone,  was  Desault  in  the 
habit  of  discovering  luxations  in  a  downward  direc- 
tion, and  was  rarely  mistaken  in  his  diagnosis.  It  is 
thus,  that,  in  a  fracture  of  the  clavicle,  the  inclined 
position  of  the  patient  is  oftentimes,  at  first  sight, 
characteristic  of  the  nature  of  his  complaint.  Beneath 
the  hollow  of  the  arm-pit  there  always  exists  a  protu- 
berance niore  or  less  perceptible,  formed  by  the  head 
of  the  humerus. 

30.  To  the  general  signs  of  luxations  of  the  hu- 
merus (28),  that  in  an  inward  direction  adds  tlie  fol- 
lowing :  the  elbow,  being  separated  from  tlie  trunk 
of  the  body,  is  carried  a  little  backward;  the  hume- 
rus seems  to  direct  itself  towards  the  middle  Of  the 
clavicle;  motions  backward  are  not  very  painful, 
while  those  in  a  forward  direction  are  extremely  so; 


116 

under  the  pectoralis  major  a  manifest  protuberance 
exists;  the  arm  is  but  Httle  longer  than  in  a  natural 
state ;  the  attitude  is  the  same  as  in  the  preceding  case.. 

31.  Should  a  luxation  in  an  outward  direction  oc- 
cur, it  would  be  pai'ticularly  characterized  by  a  hard 
tumour  under  the  spine  of  the  scapula,  by  the  direc- 
tion af  the  elbow  forward,  by  its  separation  from  the 
trunk,  and  by  a  little  increase  in  the  length  of  the  arm, 

A  protuberance  behind  the  clavicle,  an  obvious 
shortening  of  the  arm,  together  with  its  direction^ 
would  plainly  disclose  a  luxation  upwards. 

32.  The  signs  discriminative  of  tte  nature  of 
luxations  of  the  humerus,  are  not  always  accompa- 
nied by  the  same  degree  of  certainty  as  those  that 
announce  merely  its  existence.  Thus,  nothing  is 
more  difficult  than  to  determine  when  a  luxation  in- 
ward is  primitive,  and  when  it  is  consecutive,  the 
same  phenomena  being  common  to  both.  Nothing 
but  an  exact  history  of  the  disease,  stating  tlie  order 
in  which  the  phenomena  have  succeeded  each  other, 
can  throw  light  on  this  point,  which  is  the  more  in- 
teresting and  important,  as,  according  to  the  one  or 
the  other  state  of  things,  the  processes  of  reduction 
ought  to  vary.  In  the  first  case,  the  head  re-enters 
its  natural  cavity  by  a  short  route ;  whereas,  in  the 
second,  it  arrives  there  by  a  much  longer  one. 

If,  as  Petit  pretended,  there  exist  luxations  back- 
ward, sometimes  primitive,  and  sometimes  consecu- 
tive, the  same  remark  may  be  applied  to  them  wdth 
equal  propriety. 

33.  Certain  signs,  common  to  luxations  of  the 
humerus,   fi^actures  of  its  neck,  and  dislocations  of 


117 

the  scapulary  extremity  of  the  clavicle,  might  here 
create  some  uncertainty,  if  in  the  one,  the  absence  of 
a  tumour  under  the  arm-pit,  and  of  a  depression  under 
the  acromion,  did  not  prevent  a  mistake,  which  Hip- 
pocrates declared  to  be  easily  committed,  into  whichy 
according  to  Galen,  the  masters  of  the  art  of  wrestling 
fell,  and  which  Pare  cautions  us  to  avoid;  and  if,  in 
the  other,  the  appearances  proper  to  a  fracture,  did 
not  prevent  a  mistake  which  would  be  serious  in 
its  consequences,  and  which  sometimes  results  from 
the  direction  of  the  humerus,  and  the  kind  of  protu- 
berance formed  in  the  arm-pit,  by  the  end  of  the  in- 
ferior fragment.  (See  Fracture  of  the  neck  of  the  hu- 
merus J. 

§  V. 

OF  ACCIDENTS  PRODUCED  BY  THE  LUXATION". 

34.  Luxations  of  the  humerus  are  but  rarely  fol- 
lowed by  any  serious  accidents.  Sometimes  a  swell- 
ing more  or  less  considerable  appears,  immediately 
after  the  fall,  in  and  around  the  arm-pit.  This  is  the 
effect  of  an  increased  irritability  of  the  part,  and  is 
seldom  of  long  duration.  Desault's  remedy  for  it 
was  the  application  of  compresses  wet  with  vegeto- 
miner?d  water,  or  of  cataplasms  moistened  with  the 
same  liquid. 

35.  Several  authors,  particularly  Bell,  speak  (as 
if  it  were  a  familiar  accident)  of  an  oedematous  swell- 
ing of  the  whole  upper  extremity,  caused,  in  inward 
luxations,  by  a  compression  of  the  axillary  glands. 
This  phenomenon  has  not  often  occurred  in  the  Hotel- 


118 

Dkii,  except  in  luxations  of  long  standing:  and 
when  it  has  been  met  with  in  certain  cases,  very 
happy  effects  have  been  produced,  by  the  action, 
continued  for  several  days,  of  a  roller  *ipplied  widi 
considerable  tightness  after  the  reduction,  and  reach- 
ing from  the  fingers  to  the  arm-pit* 

Case  II.  Maria  ***,  falling  from  some  height, 
her  elbow  being  separated  from  her  body  and  direc- 
ted backwards,  luxated  her  shoulder  inwardly*  Seve- 
ral days  elapsed  before  she  received  any  surgical  aid. 
She  was  afterwards  admitted  into  the  Hotel-Dieu, 
where  the  displacement  was  disciovered  through  a 
very  considerable  swelling,  which  occupied  the  parts 
ai'ound  the  articulation  of  the  humerus.  The  reduc- 
tion was  accomplished,  and  the  swelling  left  to  itself, 
which,  far  however  from  disappearing,  with  the  cause 
that  produced  it,  seemed  to  gain  ground.  A  roller 
was  then  applied,  and  on  the  day  following  the  tu- 
mefaction was  reduced  to  half  its  former  size.  The 
same  means  are  continued.  The  compression  is  gra- 
dually increased,  and  by  the  ninth  day,  the  limb  re- 
stored to  its  natural  form,  performs,  as  before,  all  its 
functions. 

36.  There  is  another  accident,  on  which  authors 
have  dwelt  a  little,  which  was  known  to  Avicenna, 
and  which  oftentimes  fell  under  the  notice  of  Desault. 
I  allude  to  a  paral3^sis  of  the  upper  extremity,  the 
effect  of  compression  made  by  the  head  of  the  bone, 
in  inwai'd  luxations,  on  the  nerves  of  the  brachial  plex- 
us. This  accident  sometimes  resists  every  expedient , 
of  ait,  as  appears  from  the  following  case,  collected 
bv  mvself,  in  the  Hotel-Dieu. 


119 

Case  IIL  Maria  Dougour,  fell  on  her  right  side, 
and  experienced  immediately  all  the  signs  of  a  down- 
ward luxation.  A  surgeon  was  called,  who  moved  the 
bone  violently  in  every  direction ;  he  made  no  exten- 
sion ;  he  kept  the  patient  in  torture  for  an  hour ;  and  at 
the  expiration  of  that  time  pronounced  the  luxation  ir- 
reducible, because  the  head  of  the  bone,  instead  of  re- 
turning into  its  natural  cavity,  had  moved  inwardly. 
Indeed,  in  the  midst  of  his  unskilful  efforts,  a  conse- 
cutive luxation  inwards  had  succeeded  to  a  primitive 
one  downwards. 

On  the  same  evening,  an  evident  insensibility 
occurred  hi  the  part.  A  swelling,  joined  to  a  sense 
of  coldness,  accompanied  it.  On  the  fourth  day,  the 
paralysis  v/as  complete. 

On  the  tenth  day  the  patient  was  brought  to  the 
Hotel-Dieu,  where  the  processes  of  art  which  we 
shall  presently  describe,  replaced  the  bone,  without 
removing  the  effects  of  its  luxation. 

To  remedy  this,  irritating  means  were  employed, 
simple  at  first,  but  multiplied  and  combined  after- 
wards, and  pushed  so  far  as  to  occasion  redness  ac- 
companied by  small  blisters.  These  were  continued 
for  three  weeks ;  blistering  plasters  were  applied;  all 
in  vain ;  the  paralysis  continued,  and  as  long  as  a  year 
afterwards  the  patient  was  still  affected  with  it. 

37.  This  accident  is,  in  general,  extremely  obsti- 
nate, when,  as  in  the  preceding  case,  the  nerves  have 
experienced  a  long  continued  pressure.  Under  such 
circumstances,  the  most  powerful  means  are  often 
ineffectual.  Moxa  has  been  oftentimes  used  by  De- 
sauit,  which  he  applied  over  the  clavicle,  at  the  ^^ery 


120 

Qrigin  of  the  brachial  plexus.  The  success,  with 
which  he  at  first  applied  this  remedy,  did  not  alway^s 
accompany  his  use  of  it,  so  that  notwithstanding  se- 
veral cures  performed  by  it,  yet,  to  the  majority  of 
patients  to  whom  it  was  applied,  it  was  wholly 
useless. 

39.  But,  if  the  head  of  the  humerus  make  on  the 
nerves  but  a  momentary  pressure,  and  the  reduction 
be  accomplished  shortly  after  the  paralytic  symptoms 
occur,  oftentimes  then  the  insensibility  disappears  of 
itself,  and  the  cure  may  be  alw^ays  greatly  assisted  by 
the  application  of  powerful  stimulants;  such,  for  in- 
stance, as  volatile  liniment,  composed  of  oil  of  al- 
monds and  ammonia,  which  Desault  frequently  em- 
ployed, and  of  which  he  increased  the  strength,  so 
as  to  render  it  rubefacient. 

Case  IV.  Joanna  Saq  luxated  her  arm,  by  falling 
on  her  right  side,  in  the  month  of  July,  1788.  In  the 
evening  of  the  same  day,  all  the  precursory  symp- 
toms of  paralysis  made  their  appearance.  The  affec- 
tion was  complete  on  the  day  following. 

The  patient  was  brought  to  the  Hotel-Dieu, 
where  the  reduction,  being  accomplished,  afforded 
no  relief.  On  the  third  day,  the  pai'alysis  still  conti- 
nuing, the  volatile  liniment  was  directed,  in  the  pro- 
portion at  first  of  two  drachms  of  ammonia  to  an 
ounce  of  the  oil  of  almonds.  This  produced  no  effect. 
Being  increased  in  strength  on  the  fifth  day,  it  still 
appeai'ed  to  be  useless.  On  the  eighth  it  was  made 
of  such  a  degree  of  strength,  as  to  occasion  slight 
pustules  over  the  whole  of  the  diseased  extremity. 
On  this,  motion  began  to  return,  feeble  at  first,  but 


121 

increasing  by  degrees,  till  by  the  sixteenth  day,  it 
was  as  free  and  perfect  as  in  a  natural  state.  During 
all  the  time,  the  liniment  was  applied  twice  a  day  over 
the  arm  and  fore-arm,  which  were  at  the  same  time 
subjected  to  strong  friction  during  the  space  of  half 
an  hour. 

39.  The  pains  which  accompany  luxations  of  the 
humerus,  claim  in  general  some  attention  from  the 
practitioner.  These  have  sometimes  arisen  to  such  a 
height,  as  to  produce  real  disorder  in  the  animal  eco- 
nomy, paiticularly  in  luxations  inwardly,  where,  re- 
sulting, no  doubt,  from  the  compression  of  the  axil- 
lary nerves,  they  render  immediate  reduction  more 
necessary,  and  are  generally  removed  by  it.. 

§  VII. 

OF   THE   REDUCTION. 

40.  We  may  throw  into  two  classes  the  numerous 
means,  under  all  their  variety  of  modifications,  pro- 
posed for  the  reduction  of  luxations  of  the  humerus. 
The  one  consists  in  forcing,  by  some  mechanical 
power,  the  head  of  the  bone  into  the  cavity  from 
which  it  had  escaped,  whether  extension  has  been 
previously  employed  or  not.  The  other  is  confined 
to  disengaging  it  from  the  situation,  into  which  it 
has  been  accidentally  driven,  leaving  to  the  action  of 
the  muscles  the  care  of  its  replacement. 

In  the  first  of  these,  art  does  every  thing ;  in  the 
second,  it  only  gives  the  proper  direction  to  the  pow- 
ers of  nature.  These  latter  give  but  one  course  or 
direction  to  the  action  of  powers  externally  applied : 

17 


122 

in  the  former,  the  head  of  the  bone  always  moves  In 
the  diagonal  of  two  powers  opposed  to  each  other  at 
an  angle  more  or  less  acute. 

41.  A  history  of  the  means  destined  to  act  in  the 
first  mode,  would  be  too  tedious  to  be  introduced  in 
this  place,  would  throw  no  light  on  the  processes 
about  to  be  proposed,  and  are  detailed  at  full  length 
in  many  authors,  to  \^'hich  the  reader  is  referred.  It 
will  be  sufficient  to  observe,  that  they  aU  act  some- 
what m  the  following  manner.  Some  bod}^,  placed 
under  the  ai-m-pit,  sers^es  as  a  fulcrum,  on  which  the 
ai'm  is  made  to  move  like  a  lever  of  the  first  kind,  the 
resistance  to  v\^hich  is  constituted  by  the  displaced 
head  of  the  humerus,  while  the  power  is  applied 
either  at  the  lower  part  of  this  bone,  or  at  the  wrist. 
The  extremity  of  the  humerus  being  directed  up- 
wards and  inwai'ds,  moves  its  head  in  the  opposite 
directions,  towards  the  glenoid  cavity,  where  it  re- 
places it  with  more  or  less  facility. 

In  this  manner  acted  that  machine  so  celebrated 
among  the  ancients  and  moderns,  under  the  name  of 
*'  Atnbi  Hippocratis^''''  whether  it  was  employed  in  the 
precise  form  described  by  that  prince  of  physicians, 
or  with  the  additions  and  corrections,  infinitely  varied, 
which  it  has  received  from  Paul  of  Egina,  Ambrose 
Pare,  Duvemey,  Freke,  &c.  By  this,  a  double  mo- 
tion is  communicated  to  the  head  of  the  humerus, 
which  is,  at  the  same  time,  directed,  1st,  in  the  course 
above  mentioned;  and,  2dly,  in  such  a  manner,  as  to 
disengage  it  from  the  unnatural  situation  which  it 
occupies. 


123 

42.  Extension  by  the  arm  produces,  in  com- 
mon, the  second  effect,  and  this  is  made  in  different 
modes.  Sometimes  the  weight  of  the  body  on  one 
side,  and  puUing  by  the  luxated  Hmb  on  the  other, 
serve  t<j  produce  it;  and  such  was  the  mode  of  ac- 
tion of  the  fadder,  the  door,  and  the  club,  described 
in  the  treatise  on  fractures  by  Hippocrates,  and  reviv- 
ed in  many  modem  works.  At  otlier  times,  the  body 
was  immoveably  fixed,  and  a  powerful  extension 
made  by  the  arm.  This  was  the  mode  in  which  the 
machines  of  Oribasus  operated,  and  also  one  of  the 
methods  formerly  consecrated  in  the  public  places 
where  the  athletas  held  their  combats. 

43.  On  some  occasions,  no  extension  is  percepti- 
bly made,  but  at  the  same  time  in  which  the  extre- 
miity  of  the  humerus  is  forced  outwards  by  a  body 
placed  under  the  arm-pit,  the  surgeon  pushes  it  up- 
wards into  the  glenoid  cavity :  and  such  were  the 
other  modes  of  reduction  practised  by  the  masters  in 
the  athletic  art.  Hence  it  appears,  that  the  first  class 
of  the  numerous  means,  employed  for  the  reduction 
of  luxations,  ma}^  be  divided  into  those  Vv^hich  consist 
in  impulsion,  those  where  mere  extension  is  practis- 
ed, and  those  where  recourse  is  not  had  to  either.  My 
object  here  is  not  to  examine  into  the  inconveniences 
attending  each  of  these  means :  a  sufficient  number 
of  authors  have  already  done  this;  particularly  Petit 
and  Bell,  I  shall  only  point  out  the  disadvantages, 
which,  being  common  to  all,  ought  to  induce  them 
all  to  be  excluded  from  a  rational  mode  of  practice. 

44.  The  escape  of  the  head  of  the  bone  tlirough 
the  ruptured  and  lacerated  capsule,  constitutes  essen- 


124 

tially  the  displacement  under  consideration.  But,  it 
is  never  possible  to  ascertain  with  precision  the  place 
of  this  rupture :  how,  then,  can  the  head  of  the  hume- 
rus be  directed  towards  it  by  an  artificial  force? 

45.  However  well  prepared  for  the  purpose  the 
body  may  be^  which  is  placed  under  the  arm-pit,  to 
serve  as  a  fulcrum,  always  a  chafing  more  or  less 
troublesome,  and  oftentimes  distensions  and  serious 
lacerations  are  the  consequences  of  its  application, 
when  the  body  is  suspended  on  it,  as  in  the  mode  by 
the  door,  the  club,  &:c.  where  Petit  has  seen  a  fi-ac- 
ture  of  the  neck  of  the  humerus  occur,  and  even  a 
laceration,  followed  by  an  aneurism  of  the  axillary 
artery. 

46.  Every  one  has  not  at  his  command  the  differ- 
ent means  above  mentioned  (41  and  42),  whence  the 
difficulty  of  procuring  them,  or  of  constructing  them, 
and  the  loss  of  time,  precious  in  relation  to  the  reduc- 
tion, which  is  almost  always  easily  accomplished  in 
proportion  to  the  expedition  used;  these  chai'ges  ap- 
ply, among  many  other  means,  to  that  machine  so 
complicated,  and  so  well  known,  under  the  name  of 
the  mitten*  of  Petit. 

47.  Supposing  the  luxation  to  be  consecutive, 
how  can  mechanical  means  make  the  head  of  the  bone 
retrace  the  route  it  has  pursued  in  becoming  displa- 
ced? For  example,  if  to  a  displacement  downwards 
has  succeeded  a  displacement  inwards,  it  will  be  ne- 
cessary for  the  head  to  return  downwards  before  it 
can  re-enter  its  cavity.    But,  can  the  direction  of  the 

*  (De  mouffle  de  Petit.) 


125 

movements  be  thus  varied?  This  whole  apparatus  of 
artificial  means,  for  ever  contradictory,  oftentimes 
acts  in  an  inverse  direction  to  that  of  the  muscular 
action,  which  is  the  essential  and  chief  agent  in  the 
process  of  reduction. 

Should  the  luxation  take  plape  upwards,  the  in- 
sufficiency of  these  means  must  be  evident.  , 

48.  Perhaps,  however,  they  may  be  employed 
with  some  advantage,  when  a  primitive  luxation 
downwards  is  quite  recent,,  and  the  head  of  die  bone 
is  near  to  its  cavity.  In  such  a  case  the  lower  e:dgQ 
of  the  scapula  presents  to  it  an  inclined  plane,  along 
which  it  can  easily  glide,  when  pushed  by  some  ex- 
ternal force.  It  is  doubtless  to  this  disposition  of  the 
bone  to  replace  itself,  that  we  must  attribute  the  suc- 
cesses, greatly  exaggerated,  but  in  part  real,  on  which 
the  inventor  of  every  machine  endeavours  to  found 
the  superior  merit  of  his  mode  of  operating. 

But,  in  this  case,  it  is  useless  to  accumulate  artifi- 
cial forces,  where  natural  ones  are  sufficient,  and 
where  the  operator  may,  with  his  hands,  effect  the  re- 
duction the  more  easily,  as  he  can  with  more  accuracy 
vary  the  direction  of  his  movements. 

49.  Thus  Desault  oftentimes  employed  a  process 
which  was  attended^  with  great  success,  and  which, 
like  some  of  the  preceding,  ought  to  be  referred  to 
impulsic'ii.  The  patient  being  seated  on  a  chair  of  a 
moderate  height,  he  took  hold  of  the  hand  of  the 
affected  side,  placed  it  between  his  knees,  and  carried 
it  downward  and  backward,  for  the  purpose  of  mak- 
ing extension,  and  disengaging  the  head  of  the  bone; 
while  an  assistant  held  the  trunk  with  a  view  to  coun- 


ter-extension,  which  was  sometimes  effected  to  a 
sufficient  degree,  by  the  -weight  of  the  body  and  the 
efforts  of  the  patient.  At  the  same  time  the  hands  of  • 
the  surgeon,  applied  to  tlie  arm,  in  such  a  manner 
that  the  fingers  of  each  were  in  contact  with  the  hol- 
low of  the  arai-pit,  and  the  thumbs  with  the  external 
part  of  the  arm,  di'ew  upwards  and  a  little  outwards 
the  head  of  the  humerus,  which  in  common  returned 
wdth  ease  into  its  natural  cavity. 

50.  Petit  mentions  this  process,  not  such  as  it  is 
here  described,  but  complicated  with  the  use  of  a 
napkin  passed  under  the  arm-pit  of  the  patient,  and 
round  the  neck  of  the  surgeon,  who,  by  raising  his 
head,  drew  the  displaced  extremity  upwards.  This 
additional  mean,  always  unnecessaiy,  and  not  judici- 
ously constructed,  is  generally  ineffectual,  because, 
with  it,  the  operator  cannot  at  pleasure  vary  his 
movements.  The  heinds  alone  are  always  sufficient, 
and  a  vast  number  of  examples  attest  the  efficacy  of 
this  method,  when  employed  after  the  manner  of  De- 
sault. 

Case  VI.  Nicholas  Juan  fell  on  his  side,  his 
arm  being  separated  from  his  body,  as  he  was  cross- 
ing, in  January  1790,  the  place  Notre-Dame,  oppo- 
site to  the  Hotel-Dieu.  An  acute  pain  was  immedi- 
ately experienced;  a  protuberance  appeai'ed  sud- 
denly under  the  arm-pit;  and  under  the  acromion  a 
depression  equally  sudden.  He  was  lifted  up,  and 
carried  straight  to  the  Hospital,  where  Desault  was 
just  beginning  a  clinical  lecture.  The  luxation  being 
manifested  by  these  appeai'ances,  was  immediately 
reduced  by  the  foregoing  means.    A  few  days  rest 


127 

were  enjoined  on  the  patient,  but,  on  the  same  even- 
ing, he  proceeded  on  his  way,  blaming  himself,  for 
having  lost  half  of  his  day's  journey. 

51.  In  analogous  cases  of  very  recent  luxations 
do^vnwards,  Desault  twice  or  three  times  effected  the 
reduction  by  means  still  more  simple,  as  the  follow- 
ing case,  reported  by  Heraut,  testifies. 

Case  VII.  Maria  Louisa  Favertfell,  as  she  was 
descending  a  ladder,  and  having  luxated  her  arm, 
was  carried  at  her  request,  immediately  after  the 
accident,  to  the  Hotel-Dieu.  Desault  perceiving  the 
nature  of  the  disease,  placed,  under  the  hollow  of  the 
arm-pit,  his  left  hand,  to  serve  as  a  fulcrum  while 
with  his  right,  applied  on  the  inferior  and  external 
part  of  the  arm,  he  approximated  the  humerus  to  the 
trunk,  pushing  it  at  the  same  time  upwards.  By  this 
double  -movement,  directed  upwards  and  outwards, 
the  head  of  the  humxCrus  re-entered  its  cavity  with- 
out the  least  resistance.  The  arm  was  suspended  in 
a  sling  for  two  days,  and  on  the  fourth  the  patient  re- 
turned to  her  usual  labour. 

52.  There  exists  some  analogy  between  this  me- 
thod and  one  of  those  mentioned,  by  Hippocrates,  to 
have  been  practised  in  ancient  times,  in  the  public 
games,  where  the  exertions  of  body  exposed  those 
engaged  to  frequent  luxations. 

It  is  not  only  in  luxations  downwards,  that  the 
first  of  the  simple  processes  w^hich  I  have  mentioned 
(49),  maybe  applied.  Primitive  luxations  inw^ardlj', 
yield  sometimes  to  its  use,  and  the  Journal  of  Sur- 
gery furnishes  t-^vo  instances  of  success  in  similai' 
cases;  one  in  a  female  sixty -three  years  of  age,  and 


128 

the  other  in  one  of  fifty- one,  of  a  strong  constitu- 
tion, and  in  whom  the  reduction  was  effected  with- 
out resistance. 

53.  But,  in  general,  these  means  are  ineffectual 
and  it  becomes  necessary  to  have  recourse  to  exten- 
sion, which,  when  employed  alone,  forms  the  second 
class  of  means  intended  for  reducing  luxations  of 
the  humerus.  Many  writers  have  adopted  this  exclu- 
sively, though  some  practitioners,  indulging  their 
imagination  in  the  vast  field  of  invention,  deserted 
the  common  track,  and  had  recourse  to  various  kinds 
of  machinery.  Celsus  depended  on  extension  alone, 
in  common  cases  of  luxation  downward  and  forward. 
Albucasis  employed  no  other  means,  Douey,  Dou- 
glass, and  Heister,  among  the  moderns,  reject  uncon- 
ditionally the  use  of  machines,  as  always  useless,  and 
often  dangerous.  Finally,  Dupoui  and  Fabre,  exa- 
mined and  analysed  with  great  exactness  the  process 
of  extension,  and  pointed  out,  in  every  case,  the 
means  of  rendering  it  advantageous,  by  managing  in 
the  best  manner  the  extending  forces,  and  in  the  lux- 
ation of  the  h'.imerus,  in  particular,  to  prevent  the 
inconvenience  of  straps  placed  under  the  arm-pit  of 
the  patient,  demonstrated  the  inutility  of  the  move- 
ment commonly  called  conformation.  In  these  res- 
pects, surgery  stands  indebted  to  them  for  real 
advancement,  and  their  doctrine,  at  this  day,  very 
generally  known  and  received,  w^as  principally  redu- 
ced to  practice  by  Desault,  who  made  it  the  basis  of 
his  method  of  reduction  in  all  fractures  and  luxations. 

54.  To  proceed  to  the  reduction  of  a  luxation  of 
tlie  humerus,  it  is  necessary  to  have  such  a  number 


129 

of  assistants  as  to  be  able,  according  to  the  resistance 
of  the  parts,  to  increase  the  force  intended  to  over- 
come it.  But  two  are  commonly  sufficient.  They 
should  furnish  themselves  with  a  linen  ball,  thick 
enough  to  project  beyond  the  level  of  the  pectoralis 
major  and  the  latissimus  dorsi,  when  placed  in  the 
axilla,  and  two  straps,  one  formed  of  fiaimel  doubled 
several  times,  four  inches  broad,  and  eight  or  nine 
feet  long,  the  other  of  a  napkin  regularly  folded.  This 
latter  is  not  often  absolutely  necessary. 

Every  thing  being  properly  arranged,  the  patient 
is  seated  on  a  chair  of  a  moderate  height,  or  else  laid 
on  a  table  firmly  fixed  and  covered  with  a  simple 
mattress,  in  order  that  the  trunk,  by  being  in  a  hori- 
zontal position,  may  not  prevent  tlie  motions  commu- 
nicated to  the  arm  from  being  directed  downwards. 

55.  Desault  continued,  for  a  long  time,  to  place 
the  patient  in  the  first  of  these  positions,  which, 
though  employed  by  practitioners  generally,  is  by 
no  means  the  most  favourable.  By  adopting  it  indeed 
the  arm  may  be  very  well  drawn  in  a  transverse  di- 
rection ;  but  if,  as  oftentimes  happens,  it  becomes 
necessary  to  direct  extension  upwards  or  dov/n- 
wards,  the  assistant,  then,  being  obliged  to  elevate 
liimself,  or  to  stoop,  cannot,  in  either  of  these  atti- 
tudes; exert  his  strength  to  advantage,  but  is  confi- 
ned and  embarrassed,  and  cannot  with  ease  vary,  at 
the  pleasure  of  the  surgeon,  the  direction  in  which 
the  arm  is  drawn. 

As  far  as  relates  to  the  patient,  that  situation  in 
which  the  body  is  only  in  part  supported,  is  much 
more  fatiguing  than  one  where  the  whole  of  it  reposes 

18 


130 

equally  on  a  horizontal  plain.  Perhaps,  in  relation  to 
the  surgeon,  it  would  be  more  advantageous,  in  ena- 
blinghim  to  accomplish  the  process  of  conformation*; 
but,  as  will  be  presently  observed,  this  process  is  al- 
ways useless.  These  considerations  induced  Desault, 
in  the  last  years  of  his  practice,  to  renounce  the  first 
position,  and  have  recourse  only  to  the  second. 

56.  The  patient  being  properly  situated,  under 
the  arm-pit  of  the  affected  side  is  placed  the  linen 
ball,  on  which  the  middle  of  the  first  sti'ap  is  then 
applied.  The  two  ends  of  this  strap  being  now 
brought  obliquely  up^vards,  before  and  behind  the 
thorax,  so  as  to  meet  on  the  top  of  the  sound  shoul- 
der, and  being  held  by  an  assistant,  serve  to  fix  the 
body,  and  to  make  counter-extension,  nor  does  the 
action  of  the  strap  bear  on  the  edges  of  tlie  pectoralis 
major  and  latissimus  dorsi,  in  consequence  of  the  ball 
which  projects  beyond  their  edges.  Were  it  not  for 
this,  these  muscles,  being  pulled  upwards,  would 
draw  in  the  same  direction  the  humerus,  to  which 
they  are  attached,  and  would  thus  destroy  the  effect 
of  the  extension,  which  is  made  in  the  following 
manner. 

*  That  is,  to  draw,  or  otherwise  force  the  head  of  the  os  hu- 
meri, with  his  hands,  towards  the  glenoid  cavity,  while  the  as- 
sistants are  making  extension  and  counter-extension.  In  doing 
this,  he  must  pull  the  head  upwards,  if  it  be  lodged  in  the  ax- 
illa, backward  if  it  be  under  the  upper  part  of  the  pectoralis 
major,  &:c.  Desault,  however,  contends  that  this  assistance 
from  the  surgeon  is  unnecessary,  and  that  extension  and  coun- 
ter-extension are  alone  sufficient  to  effect  the  reduction. 

Traks. 


131 

57.  Two  assistants  take  hold  of  the  fore-arm 
above  the  wrist,  or  else  a  folded  napkin  is  fixed  on 
that  part,  having  its  two  ends  twisted  around  each 
other.  These  ends,  thus  folded  together,  are  given 
to  one  or  two  assistants,  who  begin  to  pull  in  the  di- 
rection of  the  humerus.  To  this  first  movement,  in- 
tended  to  disengage  the  head  of  the  bone  from  the 
bed  wliich  it  occupies,  another  succeeds,  which  must 
vary  according  to  the  kind  of  luxation.  If  the  luxa- 
tion be  downwards,  the  surgeon  gradually  approxi- 
mates the  ann  to  tlie  trunk,  at  the  same  time  that  he 
pushes  it  gently  upwards.  By  this  process,  the  head 
of  the  bone,  being  drawn  from  the  trunk,  and  brought 
towards  the  glenoid  cavity,  usually  re-enters  it  with 
but  little  resistance. 

If  the  luxation  be  inwards,  the  extremity  of  the 
humerus,  after  extension  according  to  the  direction 
of  the  bone,  should  be  carried  upward  and  forward, 
in  order  that  its  head  may  be  directed  backwards. 
Steps  the  very  reverse  of  these  must  be  pursued,  if 
a  luxation  in  an  outward  direction  is  to  be  reduced. 

58.  In  general,  when,  by  the  first  extension,  the 
head  of  the  bone  is  disengaged,  the  motion  commu- 
nicated to  it  by  the  subsequent  ones,  ought  to  be  in 
a  direction  precisely  opposite  to  that  which  it  pursued 
in  escaping  from  its  cavity.  But  what  are  the  valua- 
tions of  this  direction?  Extensive  experience  alone 
can  clearly  determine  this  point.  Without  experience 
the  practitioner  works  in  darkness.  The  minutije. 
or  particulars  of  the  process  of  reduction,  being  dif- 
ferent in  different  cases  and  according  to  difierent 
circumstances,  can  be  neither  foreseen,  nor  taught 
by  precept. 


132 

59.  If  the  head  of  the  bone  Experience  any  diffi- 
culty in  re-entering  its  cavity,  it  is  necessary,  when 
the  extensions  have  been  made,  to  communicate  to 
the  bone  different  movements,  varied  according  to 
the  different  directions  of  displacement,  and  regulated 
by  the  principle  just  established.  Oftentimes  this  me- 
thod effects  what  extensions  alone  cannot;  and  the 
head  of  the  bone,  carried  by  these  movements  to- 
wai'ds  its  cavity,  enters  it  while  they  are  performing. 

60.  Ifthe  luxation  be  consecutive,  then  the  first 
extension  made  in  the  direction  of  the  displaced  bone, 
is  intended  to  bring  its  head  into  the  place  where  it 
was  primitively  lodged,  in  order  that  it  may  be 
afterguards  acted  on  as  if  it  were  a  case  of  primitive 
luxation.  It  is  oftentimes  only  at  the  moment  of 
reduction,  that  it  is  practicable  to  ascertain  to  which 
kind  of  luxation  the  accident  belongs.  Indeed,  as  in 
most  cases,  the  reduction  takes  place  of  itself  when 
the  extensions  ai'e  well  executed,  if  the  head  be  con- 
secutively drawn  inward,  it  is  seen  to  descend  along 
the  internal  part  of  the  scapula,  till  it  an'ives  near  to 
the  inferior  part  of  that  bone,  and  then  to  reascend  to- 
Avards  the  rupture  in  the  capsule  through  v/hich  it 
passes  into  its  natural  situation. 

61.  I  ha^e  said  that  when  the  extension  is  pro- 
perly made,  the  reduction  takes  place  almost  spontane. 
ously.  Indeed  whatever  may  be  the  kind  of  primitive 
luxation,  it  is  evident,  that  the  m^uscles  surrounding 
the  articulation  must  be  stretched  on  one  side,  while 
tliey  are  relaxed  on  the  other;  whence  there  will 
necessai'ily  arise  a  change  both  in  their  conti-actions, 
and  in  the   direction  of  these  contractions,  and  such 


133 

is  the  nature  of  this  change,  that,  in  case  the  muscles 
act,  instead  of  bringing  the  head  towards  the  rupture 
in  the  capsule,  they  will  di'aw  it  in  another  direction, 
and  by  that  means  produce  a  consecutive  luxation. 

62.  But,  if  the  extensions  render  the  muscles 
straight,  and  restore  to  them  their  primitive  direction, 
then,  obeying  their  natural  iiTitability,  which  is  still 
further  increased,  by  means  of  the  extension,  they 
will  draw  the  head  to  the  rupture  in  the  capsule,  and 
force  it  to  re-enter  it,  wath  much  more  certainty  than 
this  can  be  done  by  the  efforts  of  the  surgeon,  who 
is  always  ignorant  of  the  precise  situation  of  this  rup- 
ture. On  the  other  hand,  if  the  extension  be  not 
judiciously  made  how  can  it  restore  to  the  muscles 
their  natural  direction?  In  such  a  case,  the  head  of 
the  bone  will  be  drawn  towards  some  other  part  of 
the  capsule  than  that  where  the  rupture  exists,  and 
hence,  the  difficulties  that  so  frequently  occur,  in  re- 
ducing luxations  of  the  humerus, 

63.  From  these  circumstances  it  follows;  1st, 
that  the  whole  art  in  the  treatment  of  luxations,  con- 
sists in  giving  to  the  extending  powers  a  proper  di- 
rection; 2dly,  that,  in  general,  the  process  of  con- 
formation is  unnecessary  and  useless;  3diy,  that  to 
reduce  a  luxation  is  not  to  replace  the  head  of  the 
bone  in  its  cavity,  by  force,  but  to  restore  the  muscles 
to  such  a  state,  as  to  enable  them  to  replace  it.  Here, 
therefore,  as  in  every  other  case,  art  is  only  the 
minister  and  handmaid  of  nature. 

There  are  instances,  however,  where  the  muscles 
cannot  act  properly  in  consequence  of  the  long  stand- 
ing or  age  of  the  luxation,  and  in  consequence  of 


134 

adhesions,  more  or  less  strong,  having  taken  place 
between  the  surrounding  parts.  In  such  cases  it  is 
necessary  to  employ  proper  measures  to  force  the 
head  of  the  bone  into  its  cavity,  as  it  cannot  be  car- 
ried thither  by  the  muscles. 

64.  Reason  concurs  with  experience,  which  is  on 
all  subjects  the  best  authority,  in  estabhshing  the 
truth  of  this  doctrine,  respecting  the  reduction  of 
luxations  of  the  humerus.  In  this  operation,  Desault 
employed,  in  general,  nothing  but  extensions,  varied 
according  to  circumstances,  until  the  muscles  thro"vvii 
into  a  favourable  state,  were  themselves  enabled  ta 
accomplish  the  reduction.  The  most  immediate  suc- 
cess constantly  crov/ned  his  practice  on  this  point. 
This  success  was,  no  doubt,  owing  to  his  judiciously 
remaining  inactive  himself,  and  suffering  the  muscles 
to  do  the  -work,  after  the  necessary  extensions  had 
been  made. 

65.  When  the  reduction  is  accomplished,  if  the 
arm,  in  consequence  of  being  very  moveable,  ap- 
pears likely  to  be  displaced  again,  it  is  necessary,  for 
a  few  days,  to  fix  it  in  such  a  manner  as  to  prevent 
all  motion;  an  object  which  may  be  effectually  at- 
tained by  Desault' 3  bandage  for  fractures  of  the 
clavicle. 

All  writers  recommend,  for  this  purpose,  the  use 
of  the  »S))ic<^  bandage.*  But  what  service  can  this 
render?  It  does  not  restrain  the  motions  of  the  hume- 

*  With  the  particular  mechanism  and  m,ode  of  action  of 
this  bandage,  I  am  unacquainted.  Nor  are  these  matters  of 
much  moment,  as  the  bandage  is,  I  believe,  entirely  out  of  use. 

Trans. 


135 

rus,  which,  hanging  down  the  side,  may  move  for- 
ward, backward,  &c.  and  produce  a  new  displace- 
ment; an  accident  that  may  be  always  prevented  by 
the  bandage  proposed. 

§  VIII. 

OF   CIRCUMSTANCES   RENDERING    REDUCTION 
DIFFICULT. 

66.  I  will  close  this  memoir  by  an  examination 
into  some  circumstances,  wliich  may  either  prevent 
reduction  or  render  it  difficult,  and  into  certain  acci- 
dents that  sometimes  accompany  it. 

I  have  said  that,  on  some  occasions,  the  rupture 
of  the  capsule,  being  too  narrow  to  admit  the  head  of 
the  humerus  to  repass  it,  and  return  to  its  cavity,  con- 
stitutes one  6f  the  principal  obstacles  to  a  reduction 
(24).  To  enlarge  this  passage,  by  further  lacerating 
its  edges,  is  evidently  the  indication  that  here  presents 
itself.  This  is  fulfilled  by  communicating  to  the  bone 
great  motion,  either  by  circumduction,  or  rotation  on. 
its  own  axis,  forcing  it  suddenly  in  dilFerent  direc- 
tions, particularly  in  that  direction  in  which  th,e  lux- 
ation has  been  produced.  Its  superior  extremity 
muse  be,  at  the  same  time,  pushed  forcibly  against 
the  ruptured  capsule,  which,  by  being  thus  pressed 
between  two  resisting  bodies,  will  suifer  a  more  ex- 
tensive rupture.  Reduction,  oftentimes  impracticable 
previously  to  these  violent  and  varied  motions,  takes 
place  of  itself  as  soon  as  they  have  been  properly 
made.  Of  this  the  practice  of  Desault  furnishes  many 
examples. 


136 

Case  VIII.  In  the  Journal  of  Surgery  are  re- 
corded two  cases,  one  by  Anthaume,  the  other  by 
Faucheron,  which  estabUsh  this  doctrine. 

John  Sehgni,  a  robust  man,  forty-four  years  of 
age,  fell  on  the  point  of  his  shoulder,  on  the  19th  of 
July  1791 ;  the  pain,  which  was  increased  by  moving 
his  arm,  and  the  swelling  which  supervened  almost 
immediately,  induced  him  to  enter  the  Hotel-Dieu. 
The  efforts  of  assistants  were  at  first  insufficient,  and 
it  was  not  till  after  a  uniform  extension  continued 
for  several  minutes,  that  the  head  of  the  humerus 
was  drawn  by  the  muscles  against  the  glenoid  cavity. 
The  bone  appeared  to  enter  the  cavity,  although  the 
persons  present  did  not  hear  the  collision  or  clashing 
of  the  articulating  surfaces,  which  is  almost  always 
perceived  in  cases  of  recent  luxation:  but  immedi- 
ately the  humerus  was  again  displaced,  without  its 
being  practicable  to  retain  it.  On  the  occurrence  of 
this  phenomenon,  Desault  conceived  that  the  head 
of  the  bone  had  pushed  before  it  the  capsular  liga- 
ment, through  which  it  could  not  pass,  in  consequence 
of  the  narrowness  of  the  opening  which  had  been 
made  at  the  time  of  the  luxation.  He  proceeded  to 
move  the  arm  forcibly  in  every  direction,  in  order  to 
enlarge  the  opening,  and  immediately  felt  a  kind  of 
laceration,  which  satisfied  him  that  his  vie^vs  were 
accomplished.  He  then  re-commenced  extension, 
which  it  was  again  necessary  to  continue,  as  at  first, 
for  some  time,  in  order  to  overcome  the  resistance  of 
the  muscles.  The  reduction  was  attended  with  no 
further  difficulty.  The  humerus  continued  still  to 
have  a  great  tendency  to  be  displaced,  and  it  was  ne- 


137 

eessary  to  employ,  for  several  days,  a  bandage  simi- 
lar to  that  for  a  fractured  clavicle. 

Case  IX.  Maria  Laiirencier,  aged  sixty,  fell  on 
her  right  elbow,  and  luxated  the  humerus  of  the  same 
side.  Eight  hours  afterwards  she  came  to  the  Hotel- 
Dieu,  on  the  eighth  of  March,  1789.  The  reduction 
was  attempted  in  the  usual  manner;  but,  although 
the  extensions  were  properly  directed,  and  the  head 
of  the  humerus  brought  against  the  glenoid  cavity,  it 
was  still  displaced  again  as  soon  as  the  limb  was  let 
go,  a  circumstance  which  created  a  suspicion,  that 
the  opening  of  the  capsule  was  too  narrow  to  allow 
the  head  of  the  bone  to  pass.  The  assistants  ceased' 
making  extension,  and  Desault,  taking  hold  of  the 
lower  extremity  of  the  arm,  impressed  on  it  great 
motion,  particularly  in  the  direction  of  the  luxation, 
for  the  purpose  of  enlarging  the  laceration  of  the  cap- 
sule. The  extensions  were  now  renewed,  and  the 
reduction  succeeded  with  great  ease. 

67.  A  second  obstacle,  more  difficult  to  be  sur- 
mounted in  the  process  of  reduction,  is  that  arising 
from  the  long  continuance  of  the  luxation.  The- 
head  of  the  bone,  having  continued  for  a  long  time  in 
the  bed  into  which  it  has  been  accidentally  thrown,, 
forms  adhesions  to  it;  the  surrounding  cellular  mem- 
brane becomes  thickened,  and  makes,  so  to  speak,  a- 
new  capsule  for  the  head,  which  opposes  its  replace- 
ment, and,  when  the  reduction  cannot  be  accom-- 
plished,  supplies  in  some  measure  the  office  of  the- 
old  joint,  by  the  movements  which  it  allows  to  take- 
place. 

19 


138 

Most  writers,  and  Bell  in  particular,  advise,  in 
such  a  case,  never  to  attempt  a  reduction,  which,  being 
of  no  avail  as  to  the  luxation,  might  prove  dangerous 
to  the  patient,  in  consequence  of  the  violence  it  would 
do  to  the  parts.  This  doctrine  was  for  a  time,  the 
doctrine  of  Desault:  but  experience,  in  his  latter 
years,  led  him  to  a  bolder  practice. 

68.  The  complete  success  which  he  experienced 
in  luxations  of  fifteen  or  twenty  da}^s  standing,  encou- 
raged him  to  make  the  attempt,  at  tlie  end  of  thirty 
and  thirty-five  days,  and  we  have,  three  or  four  times, 
during  the  two  last  years  of  his  life,  seen  him  success- 
ful in  replacing,  after  the  expiration  of  two  and  a 
half,  and  even  three  months,  the  head  of  the  bone 
•which  had  escaped,  both  through  the  inferior,  and  the 
internal  side  of  the  capsule. 

However  powerful,  and  however  long  continued 
the  extensions  were,  none  of  those  tenible  accidents 
occurred,  v^ith  which  we  are  threatened  by  authors. 
Twice  only  did  a  phenomenon  occur,  which  it  was 
difficult  to  foresee,  and  of  which  I  will  presently 
speak. 

69.  In  cases  of  tliis  kind,  it  is  necessary,  previous- 
ly to  making  extension,  to  move  the  bone  yery  for- 
cibly in  every  direction,  in  order  first  to  brea^  the 
adlieslons,  to  tear  the  condensed  cellular  membrane, 
which  serves  as  an  accidental  capsule,  and  to  produce, 
so  to  speak,  a  second  luxation,  with  a  view  to  make 
way  for  a  perfect  reduction  of  the  first.  The  straps 
being  then  applied,  as  in  ordinary  cases,  serve  the 
purpose  of  extension,  for  the  accomplishment  of 
which  the  number  of  assistants  must  be  increased. 


139 

70.  Oftentimes  the  first  efforts  are  fruitless,  and 
the  luxated  head  remains  stationary,  amidst  the  most 
violent  efforts.  Let  the  extensions  then  be  disconti- 
nued :  renew  the  forcible  motions  of  the  limb :  carry 
the  humerus  upwards,  downwards,  forward,  and 
backward:  force  the  resistances  to  give  way;  make 
the  arm  describe  a  large  arch  of  a  circle  round  the 
place  which  it  occupies;  let  the  rotatory  motions  on 
its  own  axis  be  impressed  on  it  anew;  and  then  re- 
eommence  the  extensions,  and  let  them  be  made  in 
eveiy  direction.  By  these,  the  head,  already  disen- 
gaged by  means  of  preceding  violent  motions,  will 
be  brought  to  a  level  with  the  glenoid  cavity,  and 
ultimately  replaced. 

It'may  not  be  improper  to  confirm  by  experience 
the  truth  of  these  precepts,  which  might  to  some  ap- 
pear rash,  in  consequence  of  the  changes  tliat  seem 
likely  to  occur  in  the  glenoid  cavity,  during  the  ab- 
sence of  the  head  of  the  humerus.  I  will  relate, 
among  others,  a  case  reported  by  Giraud,  second 
surgeon  to  the  Hotel-Dieu. 

Case  X.  Maria  Gauthier,  thirty- four  years  of 
age,  entered  the  Hotel-Dieu,  on  the  twentieth  of  June, 
1790,  to  be  cured  of  a  luxation  of  three  months 
standing,  produced  originally  by  a  fall  on  the  arm, 
which  was  separated,  at  the  time,  from  the  body  and 
carried  backward.  Different  surgeons  had,  at  differ- 
ent times,  attempted  the  reduction,  but  always  with- 
out effect,  and  when  every  hope  of  a  cure  appeai'ed 
to  have  expired,  Desault,  imboldened  by  reiterated 
success,  tried  whether  or  not  he  would  be  equally 
fortunate  in  this  case. 


140 

The  patient  being  placed  in  a  horizontal  position, 
as  already  directed  {55),  great  motions  were  first  im- 
pressed on  the  limb:  extensions  were  then  com- 
menced, first  in  the  direction  of  the  luxation,  and 
afterwards  forward  and  backward.  Vain  efforts;  the 
head  remains  immoveable;  new  motions  are  again 
made  in  every  direction,  and  afterwai'ds,  the  exten- 
sions are  renewed:  the  same  want  of  success.  The 
patient  being  fatigued,  the  reduction  was  deferred  till 
the  day  following,  when  the  same  trials  were,  after  a 
short  time,  attended  with  complete  success.  The 
head  being  at  fii'st  disengaged,  and  afterwards  drawn 
slowly  along  the  track  through  which  it  had  passed  in 
becoming  displaced,  at  length  re-entered  the  capsule. 
The  arm,  being  supported  by  the  usual  apparatus^ 
soon  became  oedematous,  and,  notwithstanding  the 
remedies  common  in  such  cases,  the  swelling  conti- 
nued for  two  months.  The  motions  performed  by 
the  limb  in  the  mean  time,  restored  to  it,  by  degrees, 
its  usual  suppleness;  and,  on  the  sixty-eighth  day 
after  her  entrance,  the  patient  was  discharged  cured. 

To  this  case,  I  might  subjoin  many  others,  and, 
in  particular,  that  of  John  Putot,  also  reported  by 
Giraud,  and  in  which  the  means  just  described  (69 
and  70),  succeeded  in  the  reduction  of  a  luxation  at 
the  expiration  of  the  fourth  month.  But  too  great 
an  accumulation  of  facts  distract  the  attention,  and 
add  nothing  to  conviction,  especially  when  they  arc 
already  so  plain  as  those  just  related. 

71.  But  further,  in  cases  of  this  kind,  where  a 
very  old  luxation  presents  great  obstacles  to  reduc- 
tion, although  the  attempts  made  to  reduce  it,  do  not 


141 

actually  force  the  head  of  the  bone  into  the  capsule, 
still  they  may  not  prove  entirely  useless.  By  bring- 
ing the  head  nearer  to  the  glenoid  cavity,  or  placing 
it  even  on  that  cavity,  and  making  it  form  new  adhe- 
sions there,  after  having  destroyed  its  old  ones,  the 
motions  of  the  limb  will  be  facilitated.  For,  in  cases, 
where  the  luxation  is  not  fairly  reduced,  these  motions 
will  be  always  less  impeded,  in  proportion  as  the 
hestd  of  the  bone  occupies  a  place  less  remote  from 
its  natural  situation. 

72.  A  third  obstacle,  common  to  the  reduction 
of  every  kind  of  luxation,  is  the  muscular  force,  in- 
creased by  the  irritation  of  the  displaced  bone,  beyond 
its  natural  degree.  So  great,  at  times,  is  this  force, 
that  the  head  of  the  bone  cannot  be  moved,  even  by 
the  strongest  eiforts.  What  means  should  then  be 
employed?  1st,  Those  which  diminish  general  irri- 
tability, such  as  blood-letting,  bathing,  a  relaxing  re- 
gimen, &c.  2dly,  Those  which  act  locally,  in  dimi- 
nishing the  irritability  of  the  muscles  of  the  shoulder. 
For  example :  the  application  of  emollient  cataplasms 
or  fomentations  to  the  part ;  or,  what  is  still  better, 
a  powerful  extension,  continued  for  some  time.  In 
consequence  of  such  extension,  the  muscles  of  the 
part  become  fatigued,  whence  their  contractions  arc 
succeeded  by  a  state  of  atony,  of  which  advantage 
may  be  taken  to  replace  the  bouQ.  Frequently  this 
extension  ought  to  be  continued  for  a  very  long  time ; 
and  we  have  known  Desault  not  to  complete  the  re- 
duction in  less  than  half  a  day,  or  even  a  whole  day, 
the  limb  being  suffered  to  remain  all  that  time  in  the 
apparatus  for  fractures  of  the  clavicle,  which  draws 


•      U4 

the  shoulder  and  muscles  outwards.  Thus,  in  frac- 
tures of  the  thigh,  where  muscular  contraction  pre- 
vents the  contact  of  the  fragments,  permanent  exten- 
sion previously  employed,  assists  in  producing  this 
contact. 

OF    ACCIDENTS    CONSEqUENT   TO  REDUCTION. 

73.  It  is  rare  that  any  serious  accident  follows^ 
the  reduction  of  a  luxation  of  the  humerus.  A  swell- 
ing, more  or  less  extensive,  sometimes  shows  itself 
around  the  joint,  particularly  when  extension  has' 
been  forcible  and  long  continued;  but  this,  being,' 
in  general,  easily  removed,  by  means  of  discutients, 
does  not  demand  particular  attention. 

74.  Another  accident  which  rai'ely  occurs  in' 
practice,  respecting  which  but  little  is  to  be  found  in 
surgical  writings,  and  with  which  Desault  occasion- 
ally met,  is,  a  considerable  emphysema,  suddenly- 
appearing  at  the  time  of  reduction.  In  the  midst  of 
those  powerful  extensions,  rendered  necessary  by  the 
ancient  state  of  the  luxation,  a  tumour  siiddenly  ap- 
pears under  the  pectoralis  major.  By  a  rapid  increase 
it  extends  itself  tovi^ards  the  hollow  of  the  arm-pit, 
the  whole  of  which  it  soon  occupies.  It  then  propa- 
gates itself  in  a  backward  direction,  aiid,  in  the  space 
of  a  few  minutes,  its  bulk  is  sometimes  equal  to  that 
of  the  head  of  an  infant.  A  practitioner,  if  unac- 
quainted with  the  nature  of  this  accident,  might  take 
it  for  an  aneurism,  produced  by  a  sudden  rupture 
of  the  axillary  artery,  in  consequence  of  the  violence 


143 

done  to  that  vessel  by  the  extensions  of  the  limb. 
But,  if  attention  be  paid  to  the  resistance  of  the  tu- 
mour, to  its  want  of  pulsation,  to  the  place  of  its  first 
appearance,  (which  is  usually  under  the  pectoralis 
major,  and  not  under  the  hollow  of  the  aim-pit,  to 
which  it  only  propagates  itself  afterwards,  as  Desault 
has  observed  in  similar  cases  that  fell  under  his  notice), 
to  the  action  of  the  pulse  still  continuing,  unless  the 
patient  should  faint  from  debility,  as  happened  to  the 
subject  of  the  following  case,  which  we  had  occasion 
to  witness  at  the  amphitheatre,  sometime  previous  to 
the  death  of  Desault,  and  to  the  colour  of  the  skin 
which  suffers  no  change ;  if  these  circumstances  be 
attended  to,  it  will  be  difficult  not  to  distinguish  one 
of  these  accidents  from  the  other.  In  that  now  und^r 
consideration,  discutients  applied  to  the  tumour, 
suehj  for  example,  as  vegeto-mineral  water,  and  a 
gentle  and  regular  compression  made  by  the  ban- 
dage intended  to  support  the  arm  after  reduction, 
are  the  most  efficacious  means  that  art  can  employ. 

Case  XI.  Simon  Cerisiat,  sixty  yeai's  of  age, 
presented  himself  on  the  nineteenth  of  December, 
1794,  as  the  subject  of  a  public  consultation,  which, 
every  day  preceded  the  clinical  lecture  of  Desault, 
to  receive  advice  for  a  luxation  inwai"ds,  which  he  had 
suffered  a  month  and  a  half  before,  and  for  the  re- 
duction of  which  no  attempt  had  been  yet  made. 

Convinced,  by  the  example  of  luxations  more 
ancient,  of  the  practicability  of  reducing  this,  De- 
sault undertook  it  immediately  in  the  presence  of  Ms 
pupils. 


144 

The  patient  being  laid  on  a  table,  firmly  fixed  and 
covered  with  a  mattress,  great  motions  were  impressed 
on  the  luxated  limb  upwai'd,  for\^^ard,  and  outward, 
ivitli  a  view  to  destroy  the  adhesions  contracted  with 
the  surrounding  parts.  Extensions  were  then  made  in 
the  manner  already  mentioned  (66  and  67). 

Nothing  w^as  gained  by  the  first  attempt,  the  head 
jemaining  immoveable,  in  the  midst  of  the  efforts  to 
displace  it.  Further  motions  were  made  in  every 
direction,  to  break  if  possible,  the  attachments  which 
held  it;  and  these  were  followed  by  further  exten- 
sions. 

While  these  were  making  in  a  forcible  manner, 
the  head  was  perceived  to  approach  by  degrees  to- 
wards the  glenoid  cavit}^,  near  to  the  edge  of  which 
it  reached  in  two  minutes,  and  was  at  length  replaced, 
by  a  sudden  movement  of  the  limb  from  behind 
forward. 

Scarcely  Vv'^as  the  reduction  accomplished,  when 
a  tumour  rose  suddenly  under  the  pectoralis  major, 
propagated  itself  towards  the  arm-pit,  and  occupied 
immediately  its  whole  extent. 

All  tlie  assistants,  astonished  at  the  phenomenon, 
knew  not  to  what  circumstance  to  attribute  it.  De- 
sault  himself,  a  little  embaiTassed,  thought  first  of  an 
aneurism  suddenly  produced  by  the  violence  of  the 
extension.  The  pulse  of  the  patient,  being  scarcely 
perceptible  in  the  side  affected,  and  a  syncope  which 
supervened,  appeared  at  first  to  favour  this  suspicion  : 
but  immediately  the  absence  of  a  fluctuation,  of  a 
pulsation,  and  of  a  change  in  the  colour  of  the  skin, 
the  return  of  the  pulse,  the  circumscription  of  the  tu- 


145 

tiiour,  its  resistance,  and  the  sound  caused  by  strik- 
ing on  it,  produced  a  belief  that  it  was  owing,  not  to 
an  effusion  of  blood,  but  to  a  disengagement  of  air 
tliat  had  been  confined  in  the  now  lacerated  cells  of 
the  cellular  membrane. 

Over  the  whole  of  the  swelling  were  applied  com- 
presses wet  with  vegeto-mineral  v/ater,  while  a  regu- 
lar compression  was  made  on  it  by  means  of  a  ban- 
dage, which,  at  the  same  time,  kept  the  arm  fixed 
against  the  trunk. 

In  the  night  there  occurred  severe  pains  around 
the  articulation  and  the  tumour,  accompanied  with 
high  fever,  both  which  symptoms  disappeared  on  the 
following  day.  Third  day,  a  diminution  of  the  em- 
physematous swelling;  and  an  entire  cessation  of 
fever  and  pain.  Eighth  day,  tumour  reduced  to  half 
its  original  size;  the  ai^m  made  to  perform  gentle 
motions,  and  disengaged  from  the  appai^atus;  discu- 
tients  continued.  Thiileenth  day,  tumour  entirely 
gone.  In  the  place  which  it  had  occupied  a  large 
echymosis  appeared,  produced  no  doubt,  by  a  rup- 
ture of  the  small  vessels  at  the  time  of  reduction,  but 
which,  tili  now,  had  not  been  perceptible  externally, 
in  consequence  of  the  emphysematous  swelling  of 
the  parts,  and  which  was  treated  by  the  same  means 
as  the  emphysema.  Seventeenth  day,  a  yellow  tinge, 
mixed  with  the  colour  of  the  echymosis,  an  evidence 
of  its  resolution,  which  was  complete  by  the  twenty- 
seventh  day. 

During  all  this  time,  the  patient  had  accustomed 
his  limb  to  constant  motion;  a  facility  in  the  move- 
ment of  it  had  thereby  returned;  and  he  was  perfectly 

20 


i46 

well  when  he  left  the  Hotel-Dieu,  on  the  thirtieth  day* 
from  the  time  of  his  admission,  and  the  sixty-fifth 
from  the  occurrence  of  the  accident. 


MEMOIR  VIII. 

ON  THE  FRACTURE  OF  THE  BONES  OF  THE 
FORE-ARM. 

§1. 

1.  The  fore-arm,  composed  of  two  bones,  nei- 
ther of  them  very  strong,  and  covered  below  by  a 
small  quantity  of  soft  parts,  is  exposed  still  more  than 
the  humerus,  to  the  action  of  external  bodies,  and  is 
articulated  at  the  upper  end  in  such  a  manner,  as  not 
to  yield,  like  it,  in  every  direction  to  the  impulses 
which  it  receives.  From  these  considerations,  it  is 
one  of  those  parts  where  fractures  most  frequently 
occur,  and,  in  a  comparative  view  of  affections  of 
this  kind  in  the  Hotel-Dieu,  it  has  oftentimes  held 
the  first  place. 

2.  It  would  be  useless  to  mention  here  the  dis- 
position of  the  bones  which  compose  the  fore-arm, 
their  irregulai'ly  prismatical  form,  their  thickness 
unequally  distributed,  their  direction  obviously 
different,  and  their  motions  differently  combined. 
It  is  sufficient  to  observe,  that,  for  the  perfection  of 
one  part  of  these  motions,  a  space,  wide  in  the  mid- 
dle, and  naiTow  at  the  ends,  must  separate  the  two 


147 

bones,  that,  without  this  space  the  radius,  impeded 
in  its  movements  on  the  cubitus,  would  compress  the 
muscles,  restrain  their  action,  and  would  be  unable 
to  perform  the  motions  of  pronation  and  supination; 
whence  the  fore-arm,  being  confined,  as  it  were,  to 
mei-e  flexion  and  extension,  would  not,  in  its  uses, 
correspond  to  our  wants. 

These  things  being  premised,  we  will  observe, 
that  fractures  of  the  fore-arm  may  have  their  seat,  1st, 
in  both  bones  at  the  same  time ;  2dly,  they  may  oc- 
cupy but  one  of  them :  hence  thi'ee  kinds  of  fractures 
more  or  less  different  in  their  phenomena,  their  con- 
sequences, and  their  treatment. 

FRACTURE  OF  THE  FORE-ARM. 

§  II. 

OF  THE  VARIETIES  AND  THE   CAUSES. 

3.  Fractures  of  both  bones  of  the  fore-arm, 
may  occur  either  at  the  ends,  or  in  the  middle  of  the 
limb.  Frequent  in  the  middle,  and  somewhat  com- 
mon below,  they  seldom  occur  in  its  upper  part, 
where  the  fleshy  portions  of  numerous  muscles,  com- 
bined with  a  considerable  thickness  of  the  ulna,  re- 
sist the  motions  which  tend  to  produce  them.  The 
two  bones,  though  most  commonly  broken  on  the 
same  line,  are,  however,  sometimes  broken  on  diflTer- 
ent  ones.  The  fracture  is  almost  always  single :  at 
times,  however,  it  is  double,  and  Desault,  in  particu- 
lar, was  once  called  to  a  patient,  over  whose  fore-ai-m 
the  wheels  of  a  carriage  had  passed,  and  had  broken 


148 

it  both  in  the  middle  and  at  the  lower  end,  so  that  it 
evidently  exhibited  six  fragments  distinct  from  each 
other.  The  two  middle  ones,  though  completely  in- 
sulated, united  again  to  the  others  with  but  very  little 
deformity.  Like  all  other  similar  affections,  these 
may  be  rendered  compound  by  wounds,  splinters, 
Sec.  circumstances  which,  as  they  fall  within  the  ge- 
neral class  of  such  injuries,  will  not  be  treated  of  at 
present. 

14.  They  occur,  in  general,  in  two  ways,  being 
the  result,  sometimes  of  the  action  of  external  bodies, 
immediately  applied,  and  at  other  times  of  the  same 
action,  operating  by  way  of  a  counter- stroke.  The 
occasional  percussion  of  a  body  on  the  fore-ai'm,  fur- 
nishes an  example  of  the  first  mode  of  fracture.  This 
is  much  more  frequent,  in  general,  than  the  other, 
which  usually  arises  from  a  fall  on  the  wrist;  but,  in 
such  a  case,  as  it  is  the  large  lower  end  of  the  radius 
that  forms  the  principal  point  of  articulation  with 
the  hand,  that  bone  alone  sustains  almost  all  the  force 
of  the  stroke,  and  is  very  generally  the  exclusive  seat 
of  tlie  fracture. 

§  III. 

OF   THE    SIGNS   OR    APPEARANCES. 

It  is  in  general  difficult  to  be  mistaken  with  re- 
spect  to  the  signs  which  characterize  fractures  of  the 
fore-arm.  A  mobility  of  the  limb  where  it  was  before 
inflexible;  a  crepitation  almost  always  easily  per- 
ceived; a  depression,  sometimes  evident,  at  the  place 
of  division;  a  protuberance  sometimes  formed  under' 


149 

the  skin  by  the  fragments ;  pain  produced  by  the 
motion  of  the  part ;  a  crack  sometimes  heard  by  the 
patient,  at  the  moment  of  the  accident ;  an  inability 
to  perform  the  motions  of  pronation  and  supination; 
the  almost  constant  semi-flexion  of  the  fore-arm; 
such,  together  with  the  phenomena  common  to  all 
fractures,  are  those  which  essentially  characterize 
this,  and  wdiich  must  generally  remove  all  doubts 
which  the  swelling  of  the  limb  may  temporarily  cre- 
ate respecting  its  existence. 

6.  There  is  a  circumstance,  however,  where  a  frac- 
ture near  to  the  joint  of  the  wrist,  may  give  rise  to 
appearances  similar  to  a  luxation  of  that  part.  In  both 
cases,  indeed,  a  convexity  behind,  and  a  depression 
before,  or  the  reverse,  are  perceived,  and  are  the 
effect  of  a  displacement  of  the  fragments.  But  the 
styloid  apophysis  being  cai'efully  examined,  will 
always  determine,  according  as  it  is  found  above  or 
below  the  deformity,  from  which  of  the  two  causes 
the  deformity  arises.  Besides,  a  greater  mobility  in 
one  than  in  the  other  affection,  and  a  crepitation,  w  ill 
guard  the  practitioner  from  an  error,  into  Vv  hich  I 
saw  a  surgeon  fall  in  the  presence  of  Desault,  Vvhom 
he  called  on  to  consult,  in  the  case  of  a  child  six  years 
old,  which  laboured  under  a  supposed  luxation, 

OF   DISPLACEMENT. 

7.  Most  of  the  phenomena  which  accompany 
fractures  of  the  fore-ai-m  (5),  are  evidently  the  result 
of  a  displacement  of  the  fragments ;  a  displacement^ 
not,  in  general,  very  perceptible  in  the  longitudinal 


150 

direction  of  the  bones,  because  the  muscular  action, 
tending  to  produce  it  in  that  direction,  is  not  very 
powerful.  When  it  does  occur  in  this  way,  it  is  most 
frequently  the  immediate  effect  of  the  stroke  that 
produced  the  fracture. 

8.  But  it  is  different  with  respect  to  a  displace- 
ment in  the  cross  direction  of  the  bone.  Here  the 
cause  of  the  separation  of  the  broken  ends,  may  be 
the  same  with  the  cause  of  their  fracture,  as  happens 
in  the  passage  of  a  carriage  w^heel  over  the  limb^  or 
in  the  falling  of  some  body  against  it;  and  then,  1st, 
the  fragments  are  separated  from  before  backward, 
or  contrarj^wise,  and  hence,  a  protuberance  on  the 
one  side  of  the  limb,  and  a  depression  on  the  other; 
2dly,  or  else  they  are  pressed  against  each  other  late- 
rally from  without  inwards.  From  this  latter  cause 
arises  that  inequality  which  the  limb  exhibits  at  the 
place  of  the  fracture ;  the  slight  depression  which  it 
manifests  on  its  sides ;  and  the  protrusion  or  bulging 
out  of  its  anterior  and  posterior  surfaces,  by  means  of 
the  mass  of  muscles  which  are  pushed  in  these  direc- 
tions, by  the  approximation  of  tlie  fragments  to  each, 
other. 

9.  A  proper  reduction  removes  the  first  kind  of  dis- 
placement, namely,  that  which  occurs  in  the  cross  di- 
rection of  the  bone  backward  or  forv/ard  (8) ;  and  un- 
less an  external  force  be  applied  anew,  it  does  not  again 
return.  On  the  contrary,  how  exact  soever  the  reduc- 
tion may  be,  in  the  second  kind,  namely,  that  which 
takes  place  laterally  from  without  inwards,  the  frag- 
ments are  soon  found  to  have  approached  each  other 
again.   Above,  the  pronator  teres  presses  the  superior 


151 

fragment  of  the  radius  against  that  of  the  ulna ;  below, 
the  two  fi^actured  extremities  are  pressed  against  each 
other,  by  the  contractions  of  the  pronator  quadratus. 
From  this  double  cause  arises,  unless  something  pre- 
vent it,  the  contact  of  the  four  fractured  ends,  which 
haye  been  sometimes  found  united  together  by  a 
common  callus,  as  is  proven  by  several  cases  sent  ta 
Desault,  and  by  the  cases  of  different  patients  admit- 
ted into  the  Hotel-Dieu,  after  having  undergone  an 
improper  treatment.  In  such  cases,  the  movements 
of  pronation  and  supination  being  entirely  destroyed, 
are  but  imperfectly  supplied,  as  Duvemey  remarks, 
by  those  of  a  rotation  of  the  arm. 

But  if  the  four  broken  ends  should  not  even  be 
joined  together  by  a  common  callus,  still  the  space  be- 
tween the  bones  being  evidently  diminished,  impedes 
muscular  action  and  the  motions  of  the  limb  depend- 
ing thereon, 

OF  THE   REDUCTION. 

10.  It  follows  from  what  has  been  said  on  the  dis- 
placement of  the  fragments  (8),  and  on  the  causes 
which  have  a  constant  tendency  to  re-produce  this 
displacement  (9),  that  the  extending  forces,  intended 
to  remove  it,  should  be,  in  general,  less  powerful 
than  in  most  other  fractures,  because  their  principal 
object  is,  to  restore  to  the  limb  its  natural  length, 
which  is  here  but  very  little  affected. 

11.  Previously  to  the  application  of  these,  it  is 
necessaiy ,  according  to  the  precept  of  Hippocrates,  to 


152 

place  the  fore-arm  in  a  middle  state  between  pronation 
and  supination,  flexion  and  extension.  This  position 
is  highly  favourable  to  the  relaxation  of  the  muscles, 
and  is  that,  above  all  others,  as  the  father  of  medicine . 
observes,  which  those  who  have  sustained  a  fracture 
naturally  assume,  and  w^hich  alone  they  can,  for  a 
long  time,  retain,  without  experiencing  any  inconve- 
nience. 

12.  The  fore-arm  being  thus  placed,  an  assistant 
makes  extension,  by  taking  hold  of  the  four  fingers ;, 
a  mode  to  be  adopted  in  preference  to  that  of  Petit, 
who  directs  us  to  make  extension  at  the  wrist;  for  the 
real  momentum  or  force  of  a  power  is  in  the  inverse 
ratio  of  its  distance  from  the  place  of  resistance. 
At  the  same  time,  another  assistant  makes  counter- 
extension  on  the  humerus,  which  he  grasps  with  both 
his  hands,  in  such  a  manner,  that  his  thumbs  corres- 
pond to  the  back  part  of  it,  while  his  fingers  cross 
each  other  anteriorly. 

13.  It  further  follows,  from  what  was  said  (8  and 
9),  that  the  process  of  conformation,  so  often  useless 
and  even  injurious,  in  other  fractures  of  bones,  is  ne- 
cessary here,  to  restore  to  the  fragments  that  exact 
contact  M^hich  they  have  lost,  in  a  transverse  direc- 
tion. If  the  displacement  be  forv/ard,  the  surgeon 
pushes  both  fragments  backward,  v/hile  the  assist- 
ants maintain  the  extension.  If  the  bones  project  back- 
wards, they  must  be  pushed  in  the  contrary  direc- 
tion. As  to  a  lateral  displacement  (8)  in  which  the 
broken  ends  approach  each  other,  it  is  not  altogetlier 
useless,  as  Petit  observes,  to  endeavour  to  remove 
it,  by  forcing  the  muscles  into  tiie  space  between  the 


153 

bones.  This  is  done  by  making  a  moderate  presstire 
on  the  anterior  and  posterior  surfaces  of  the  fore-arm, 
in  order  that  the  bones,  being  thus  removed  from 
each  other,  may  come  in  contact  with  their  broken 
«nds.  If  this  be  done,  when  tiie  apparatus  is  first  ap- 
plied, the  reduction  is  attended  widi  but  Uttle  diffi- 
culty, and  the  ends  of  the  fragments  are  easily  retain- 
ed in  apposition. 

§  VL 

'OF    THE    MEANS    OF    MAINTAINING    THE 
REDUCTION. 

14.  Our  forms  of  app^atus  are  nothing  but 
means  of  continuing,  for  a  long  time,  that  state  of 
things,  which  extension  and  the  process  of  conform- 
ation temporarily  produce  at  the  time  of  reduction. 
This  principle,  though  generally  acknowledged,  was 
particularly  neglected  in  such  fractures,  as  that  now 
under  consideration,  till  the  time  of  Petit,  wlio  made 
it  the  basis  of  his  practice.  Before  him,  there  was  a 
common  inconvenience  attached  to  every  kind  of 
bandage.  The  two  bones  being  pressed  against  each 
other,  by  circular  rollers  applied  externally,  were 
thus  drawn  in  that  very  direction,  in  which  the  action 
of  the  pronatci'  muscles  already  tended  to  displace 
them;  because,  the  form  of  the  fore-arm  being  ir- 
regular, made  these  rollers  act  more  powerfully  on 
its  lateral  parts,  where  it  is  very  convex,  than  either 
behind  or  before,  where  it  is  very  flat.  It  is  well 
known  tliat  bandages  will  make  the  greatest  pressure 

21 


154 

on  the  most  projecting  parts  of  the  limbs  round 
which  they  are  applied;  so  that,  if  the  fore-arm  be 
bound  or  pressed  on  behind  and  before  with  a  force 
equal  to  one,  it  will  sustain  laterally,  that  is,  on  its 
sides  or  edges,  a  pressure  equal  to  two.  Hence  results, 
not  only  a  tendency  in  the  radius  to  approach  the  ul- 
na, but  also,  a  want  of  resistance  in  the  muscles  situ- 
ated on  the  posterior  and  anterior  sides  of  the  fore- 
arm. For  these  muscles  being,  from  their  flatness, 
less  compressed  than  the  bones,  give  way,  and  do 
not,  by  forcing  themselves  between  them,  .oppose 
the  approach  of  the  bones  to  each  other. 

15.  Such  was  the  disadvantage  of  the  apparatus 
of  Hippocrates,  consisting  of  one  roller  applied  im- 
mediately on  the  skin,  of  a  many-tailed  bandage  in- 
tended to  retain  this,  and  of  four  splints,  applied  on 
the  seventh  day,  and  secured  by  another  roller.  Such 
was  also  the  inconvenience  of  several  bandages,  pro- 
posed after  the  time  of  Hippocrates,  by  different  au- 
thors, who  modified  his  without  improving  it,  and 
who,  in  attempting  to  alter  it,  even  added  to  its  im- 
perfections. Thus,  the  compresses  with  which  the 
limb  was  first  covered,  previously  to  the  application 
of  the  rollers,  served  only,  by  becoming  vrrinkled,  to 
render  the  compression  unequal,  fatiguing,  and  even 
painful  to  the  patient.  In  like  mamier  the  pasteboai'd, 
which  many  authors,  particularly  Duvemey,  have 
substituted  for  splints,  and  which  a  majorit}^  of  prac- 
titioners employ,  even  at  the  present  day,  soon  be- 
coming softened  by  moisture,  bends  without  resist- 
ance, becomes  incapable  of  preventing  a  displace- 


155 

ment,  and  has  at  least  the  inconvenience  of  being 
useless.* 

16.  Is  it  to  be  wondered  at  then  that  a  perfect 
cure  of  fractures  of  the  fore-arm  has  been  regarded 
as  a  thing  of  so  much  difficulty,  and  that  most  authors 
should  have  advised  practitioners,  as  a  thing  of  pru- 
dence, to  warn  the  patient  of  its  being  impracticable 
to  cure  him,  without  the  loss  of  the  motions  of  pro- 
nation and  supination?  Thus,  in  like  manner,  it  was 
formerly  declared,  that  a  constant  deformity  was  the 
necessary  consequence  of  fractures  of  the  clavicle. 

17.  Petit  first  conceived,  that  he  discovered,  in 
the  very  means  destined  to  prevent  the  displacement, 
the  cause  of  its  being  continued,  and  that,  in  order 
to  be  effective,  the  bandage  ought  to  do  constantly 
what  the  hands  of  the  surgeon  do  at  the  time  of  re- 
duction (13);  that  is,  it  ought  to  oppose  to  die  unre- 
mitting action  of  the  pronators,  a  resistance  equally 
unremitting,  by  pressing  the  muscles  into  the  inter- 
stice between  the  bones.  But,  after  having  discover- 
ed the  end  to  be  attained,  he  accomplished  it  only  in 
an  imperfect  manner.  For  by  first  applying  a  roller 
immediately  round  the  fore-arm,  he  reproduced,  in 
part,  the  very  inconveniences  and  disadvantages  he 
wished  to  prevent,  by  placing  anteriorly  and  posteri- 
orly two  long  and  thick  graduated  compresses,  in- 
tended to  keep  the  bones  asunder,  by  forcing  the 
muscles  between  them. 

*  On  this  point  Desault  is  certainly  mistaken.  Paste-board, 
when  of  a  proper  thickness  and  well  applied,  makes  an  excel- 
lent splint  for  fractures  of  the  fore-arm.  It  moulds  itself  to  the 
form  of  the  arm,  sits  easy,  and  retains  the  fracture  extremely 
well.  Trans, 


156 

18.  Duvemey,  more  judicious,  proposed  to  place 
the  graduated  compresses  of  Petit  on  two  circular 
compresses,  previously  applied  round  the  fore-arm^ 
But  what  availed  these  circular  compresses?  If  thej^ 
be  drawn  tighty  will  they  not  produce  that  approxi- 
mation of  the  bones  which  the  surgeon  wishes  to 
avoid?  And  if  they  be  not  tight,  they  will,  in  conse- 
quence of  their  loose  and  pliable  state,  fcam  trouble- 
some and  inconvenient  wrinkles,  without  being  pro- 
ductive of  any  good  to  counterbalance  this  incon- 
venience, 

19.  It  was  from  these  different  consideration Sy 
that  Desault  modified,  as  I  am  about  to  mention,  the 
apparatus  for  fractures  of  the  fore-arm.  To  a  great 
degree  of  simplicity,  this  apparatus  unites,  when  thus 
improved,  great  ease  to  the  patient,  and  its  advan- 
tages ai'e  proven  by  the  freedom  in  the  different  move- 
ments of  the  arm  always  experienced  by  the  nume- 
rous patients,  whom  he  was  called  to  attend.  The 
pieces  of  the  apparatus  are,  1st,  Two  graduated  com- 
presses, one  of  them  of  such  a  length  as  to  extend 
from  the  elbow  to  the  wrist,  and  the  other  from  the 
wrist  to  the  fold  of  the  arm  on  the  inside.  They  are 
to  be  formed  each  of  a  single  piece  of  linen,  folded 
seven  or  eight  times  on  itself,  in  such  a  manner,  that 
the  lov/er  fold  may  be  an  inch  wide,  while  the  others^ 
laid  on  top  of  each  other,  gradually  diminish  in  width 
to  the  last.  The  thickness  of  these  compresses  ought 
to  be  less  in  very  fat  persons,  where  the  anterior  and 
posterior  surfaces  of  the  arm  are  more  convex.  2dly, 
A  roller  about  four  yards  and  a  half  long,  and  four 
inches  wide.  3dly,  Four  thin  but  Ltlff  wooden  splints^ 


U7 

long  enough  to  reach,  one,  from  the  fold  of  the  arm 
to  the  wrist,  the  second,  from  the  interval  or  TioUow 
space  between  the  olecranon  and  the  condyl  to  the 
same  part,  the  third  from  the  internal  condyl  of  the 
humerus  to  the  styloid  process  of  the  ulna,  and  the 
fourth  from  the  external  condyl  to  the  styloid  apo- 
physis of  the  radius.  The  breadth  of  tiie  two  first 
ought  to  be  double  that  of  the  other  two,  as  the  latter 
occupy  a  space  of  but  half  the  width  of  that  occupied 
by  the  former. 

20.  Every  thing  being  arranged,  the  reduction 
is  to  be  executed  as  already  directed  (11 — 13);  and 
while  the  extensions  are  still  continued,  the  surgeon 
wets  with  vegeto-mineral  water,  or  some  other  dis- 
cutient  liquid,  the  graduated  compresses,  and  places 
them  on  the  anterior  and  posterior  part  of  the  fore- 
arm, (which  must  be  firmly  supported  in'  a  state  be- 
tween that  of  pronation  and  supination,  11),  in  such 
a  manner,  that  their  broadest  part  or  base  may  be 
in  immediate  contact  with  the  limb.  He  then  secures 
them  with  a  roller  wet  with  the  same  liquid,  the  casts 
of  which,  being  first  fixed  at  the  place  of  the  fracture, 
descend  obliquely  to  the  wrist,  and  are  secured  at 
the  hand  by  being  passed  between  the  thumb  and 
the  fore-finger.  Running  across  the  back  of  the 
hand,  the  roller  then  reascends,  either  by  oblique  or 
reverse  turns,  according  to  the  inequalities  of  the 
fore-arm,  till  it  reaches  the  elbow.  Here  the  surgeon 
relinquishes  the  roller,  giving  it  into  the  hand  of  an 
assistant,  and  places  the  four  splints  on  the  parts  al- 
ready mentioned  (19),  while  the  hands  of  a  second 
assistant  secures  them,  by  grasping  them  all  at  their 
lower  end,  next  to  the  ^^Tist.    The  surgeon  then  re- 


158 

sumes  the  roller,  and,  in  order  to  fix  the  splints  im- 
moveably,  descends  with  it  along  the  fore-arm  by 
circular  casts^  till  he  reaches  the  hand,  where  he 
finishes. 

There  is,  in  the  application  of  this  bandage,  an 
essential  precaution  to  be  observed;  which  is,  that  as 
each  turn  of  the  roller  passes  over  the  graduated  com- 
presses, the  surgeon  ought  to  press  on  these  com- 
presses with  the  thumb  and  fore-finger  of  his  left 
hand,  in  order  that  the  muscles,  by  being  forced  into 
the  interstice  between  the  radius  ajid  ulna  may  pre- 
vent their  approximation,  which  would  produce  an 
inequality  in  the  compression  made  by  the  apparatus, 

21.  After  the  application  of  the  apparatus,  if  the 
patient  be  obliged  to  keep  his  bed,  the  fore-arm  is  to  be 
extended  on  a  pillow,  taking  care  to  keep  it  always  half- 
bent,  and  guarded  by  hoops  from  the  w^eight  of  the 
bed-clothes.  But  if  the  fi'acture  be  not  a  compound 
one,  and  if  the  fall  has  done  no  injury  to  the  system 
in  general,  it  is  unnecessary  to  confine  the  patient  to 
a  position  wearisome,  and  oftentimes  insupportable 
to  many  persons.  Then  the  limb  is  to  be  suspended 
in  a  sling,  which  is  always  sufficient  to  support  it, 
without  having:  recourse  to  the  kind  of  hollow  case 
recommended  by  Bell,  which  is  seldom  at  hand,  and 
the  use  of  which  must  be  extremely  inconvenient. 

22.  The  subsequent  treatment  to  be  adopted  in 
such  fractures  is  simple  and  easy :  to  wet  the  appa- 
ratus daily,  for  a  few  days,  wdth  vegeto-mineraJ  water, 
to  ob^date,  by  proper  means,  the  accidents  that  may 
occur;  to  renew  the  application  of  the  roller  at  the 
end  of  eight  days,  or  perhaps  later,  according  to  the 
degree  of  its  relaxation ;  to  repeat  this  application  two 


159 

or  tliree  times  during  the  course  of  the  treatment ;  to 
allow,  at  first,  but  light  diet,  which  may  be  after- 
wards more  solid,  and  given  in  larger  quantity,  and 
to  admit  finally  of  a  return  to  the  patient's  usual  mode 
of  hving:  such  was,  in  cases  of  fi^acture,  the  prac- 
tice of  Desault,  which  was  always  attended  with 
happy  effects. 

23.  Sometimes  a  considerable  swelling  occurs, 
after  the  application  of  the  bandage,  on  the  back  and 
face  of  the  hand;  small  blisters  appear  between  the 
fingers;  the  patient  experiences  sharp  pains  along 
the  fore -arm;  and  other  small  blisters  rise  on  its  sur- 
face. It  is  then  necessary  to  remove  the  apparatus, 
to  open  the  blisters  by  pricking  the  cuticle,  and  dress 
the  part  with  cerate  spread  on  linen  rags ;  replace  the 
apparatus,  making  it  less  tight  than  before,  taking  care 
to  renew  it  every  day,  till  the  excoriation  be  entirely 
gone.  This  accident,  of  no  great  consequence  in 
itself,  has  frequently  occurred  to  Desault,  although 
the  rollers  w^ere  applied  at  first  with  but  a  moderate 
degree  of  tightness. 

24.  The  consolidation  being  completed  generally 
in  twenty-four  or  twenty-five  days,  leaves,  at  this 
time,  a  little  stiffness  in  the  joints,  in  consequence  of 
their  having  remained  so  long  without  motion:  the 
movements  of  pronation  and  supination  are  perform- 
ed but  imperfectly.  Their  return  is  facilitated  and 
hastened  by  fi'equent  exercise  of  the  limb,  as  well  at 
its  junction  with  the  os  humeri,  as  in  its  own  proper 
joints ;  and,  in  general,  by  the  fifteenth  or  twentieth 
day  fi"om  the  removal  of  the  apparatus,  things  are  in 
the  same  state  in  which  they  stood  before  the  fracture. 


160 

FRACTURE  OF  THE  RADIUS. 
§  VII. 

OF   THE   CAUSES   AND   THE   DISPLACEMENT. 

25.  The  radius,  which  is  the  moveable  and  almost 
the  only  support  or  abutment  of  the  hand,  receives,  in 
falls  on  that  part,  a  much  greater  share  of  the  shock 
than  tlie  ulna,  which  is  joined  to  the  hand  by  only  a 
small  surface.  Hence,  witliout  doubt,  arises  the 
greater  frequency  of  tlie  fractures  of  the  radius ; 
fractures  ^vhich,  v.  hen  produced  by  falls  on  the  hand, 
are  evidently  the  result  of  a  counter- stroke.  Often- 
tinjes  also  this  bone  is  broken  by  the  immediate  ac- 
tion of  external  bodies,  because  it  is  defended  below 
with  but  a  thin  covering  of  muscles. 

In  whatever  way  the  fracture  may  be  produced, 
it  occurs  in  the  middle  or  at  the  extremities  of  the 
bone;  very  rare  near  its  articulation  with  the  os  hu- 
meri, it  is  more  common  in  its  middle;  but  more 
frequent  still  at  its  lower  end.  The  difference  arises 
probably  from  this  circumstance,  that,  in  falls  on  the 
wrist  or  hand,  the  shock  is  weakened  and  lost  in  pro- 
portion as  it  is  propagated  upwards. 

26.  In  such  fractures,  displacement  is  almost  con- 
stantly observable  in  the  thickness  or  cross  direction 
of  the  bone  and  fore-arm,  and  is  produced  by  the 
action  of  the  pronator  muscles,  which,  by  forcing  die 
fragments  of  the  radius  towards  the  ulna,  tend  to  di- 
minish the  interval  between  the  bones.  The  ulna  re- 
maining unbroken^  always  prevents  any  displacement 


161 

in  a  longitudinal  direction.  The  first  kind  of  dis- 
placement is  the  more  perceptible,  in  proportion  as 
the  fi-acture  is  nearer  to  the  middle  part  of  the  radius, 
where  the  bones  are  at  the  greatest  distance  from  each 
other.  This  displacement  is  seldom  outwards,  be- 
cause the  interosseous  ligament  prevents  that:  yet 
experience  furnishes  some  exceptions  to  this  rule. 

Case  I.  Desault  was  called,  in  the  month  of 
July,  1781,  to  visit  a  mason,  who,  sleeping  at  the 
foot  of  a  wall,  with  his  fore-arm  stretched  out,  re- 
ceived on  the  anterior  part  of  it,  a  round  stone,  of  the 
size  of  a  bowl,  which,  falling  from  a  scaffold,  fractured 
the  radius  in  its  middle,  and  produced  a  large  contu- 
sion, accompanied  by  an  enormous  swelling,  to  which 
the  usual  discutient  remedies  were  applied.  On  the 
fifth  day  the  swelling  had  in  part  disappeared;  but 
then  there  was  discovered  a  very  evident  protube- 
rance of  the  inferior  fragment,  which,  by  pointing 
outwards,  separated  itself  from  the  superior  one, 
which  remained  nearly  in  its  place.  The  interval  be- 
tween the  bones  was  evidently  increased  below. 

The  fracture  was  reduced  by  pressing  the  lower 
fragment  inwai'ds,  and,  instead  of  employing  gradua- 
ted compresses  the  whole  length  of  the  limb,  they 
reached  only  to  its  middle,  along  the  part  correspond- 
ing to  the  superior  fragment.  The  roller  was  drawn. 
a  little  tighter  below  than  above,  in  order  to  keep  the 
inferior  part  of  the  radius  near  to  the  ulna. 

By  being  treated  afterwards  in  the  usual  m.ode, 

the  fracture  was  cured.  But,  in  consequence  of  being 

over- stretched  by  the  separation  of  the  bones,  the 

ligaments  of  the  wiist  became  the  seat  of  a  tedious 

22 


162 

fymphatic  swelling,  which  left  behind  it  some  degree 
of  stiffness. 

27.  Examples  of  this  kind  occur  too  rarely  to 
affect  the  general  law  relative  to  the  direction  of  the 
displacement  of  a  fractured  radius,  a  displacement 
which,  if  not  properly  treated,  makes  the  fragments 
unite  in  such  a  manner  as  to  form  an  angle  pointing 
inwardly  towards  the  ulna,  as  is  evinced  by  a  percep- 
tible depression  under  the  cuticle.  In  such  a  case, 
fi'om  this  contraction  or  narrowing  of  the  interval  be- 
tween the  bones,  arise  the  inconveniencies  already 
m,entioned  (9). 

^  VIIL 

OF  THE   SIGNS. 

28.  The  diagnosis  of  fractures  of  the  radius  is  in 
general  easy,  when  they  occur  at  the  lower  end,  or  in 
the  middle  (25).  In  these  two  cases,  a  depression 
more  or  less  perceptible,  on  the  external  side  of  the 
fore-arm ;  an  inability  to  perform  pronation  or  supi- 
nation, by  the  action  of  the  muscles  alone;  and  a  se- 
vere pain,  necessarily  resulting  from  moving  the  bone 
in  this  two-fold  direction.  Such  are  the  particular 
signs  or  appearances  which  first  disclose  the  existence 
and  the  place  of  the  fracture.  The  reality  of  the  acci- 
dent is  afterwards  more  fully  confirmed  by  the  signs 
common  to  all  fractures,  namely,  the  flexibility  of  the 
bone,  the  crepitation  perceived  by  moving  it  in  dif- 
ferent directions,  &c. 

29.  Desault  cautioned  his  pupils  not  to  confound 
this  last  sign  or  symptom  with  a  kind  of  noise,  some* 


163 

times  heard  in  the  sheaths  of  the  tendons  of  the  ex- 
tensor longus,  extensor  brevis,  and  abductor  longus; 
a  noise  resulting  from  a  filtration  of  synovial  fluid  into 
the  sheaths,  or  produced  by  some  other  cause.  But, 
besides  this  crepitus  in  the  sheaths  being  a  very  rare 
occurrence,  it  is  always  easy  to  distinguish  it  from  a 
crepitation  of  the  bone,  by  this  circumstance,  that 
the  first  is  heard  on  merely  pressing  the  parts,  but 
the  latter  only  by  making  the  bony  surfaces  rub 
against  each  other.  Besides,  by  an  experienced  ear 
there  is  no  danger  of  any  mistake  being  committed. 

30.  If  the  fracture  exist  at  the  upper  end,  the  thick 
muscular  covering  which  there  surrounds  the  radius, 
renders  the  diagnosis  more  difficult.  Petit  has,  how- 
ever, thrown  some  light  on  the  subject,  by  judiciously 
advising  to  place  one  hand  on  the  upper  extremity  of 
the  radius,  and  with  the  other  to  make  the  fore-arm 
rotate  on  this  bone.  The  solution  of  continuity  or 
fracture  will  be  rendered  evident,  if,  in  the  midst  of 
these  motions,  the  head  remain  stationar}^  But  if,  on 
the  other  hand,  it  rotate,  it  has  sustained  no  injuiy. 
These  two  circumstances  can  be  easily  explained; 
but,  it  is  not  so  easy  for  the  practitioner  to  avail  him- 
self of  them  in  every  case.  This  precept  may  also  be 
applied  in  cases  where  a  considerable  swelling,  occu- 
pying the  whole  fore- arm,  conceals  from  the  touch 
of  the  surgeon  the  fragments  of  the  bone,  even  when 
broken  in  the  middle. 


164 


§  IX. 

or   THE   REDUCTION,    AND    THE   MEANS  OF    MAIN- 
TAINING  IT, 

31.  The'reduction  of  a  fracture  of  the  radius  is  ef- 
fected in  nearly  the  manner  already  described  for  that 
of  the  two  bones  of  the  fore-arm  (10 — 13),  except 
that,  here,  the  extension  must  be  less,  because 
there  exists  no  displacement  in  a  longitudinal  direc- 
tion (26). 

To  remove  that  v^^hich  exists  in  a  cross  direction, 
an  assistant  whose  business  it  is  to  make  extension, 
places  the  hand  in  a  state  of  adduction,  for  the  pur- 
pose of  removing  the  inferior  fragment  outwards. 
This  precept  cannot  be  applied  to  much  advantage, 
if  the  division  exist  towards  the  upper  end,  on  ac- 
count of  the  interosseous  ligament. 

At  the  same  time  the  surgeon  endeavours  to  bring 
the  ends  of  the  bone  into  perfect  contact,  by  pushing 
them  in  a  direction  opposite  to  that  of  their  displace- 
ment; and  when  he  has  attained  this  end,  he  begins 
the  application  of  a  bandage  or  appai'atus  the  same  as 
that  already  described  (19  and  20),  with  this  differ- 
ence, that  as  the  ulna  is  here  sound,  and  performs,  in 
relation  to  the  fractured  radius,  the  office  of  a  natural 
splint,  it  is  unnecessary  to  place  an  artificial  one  be- 
tween the  internal  condyl  of  the  humerus,  and  the 
styloid  apophysis  of  the  ulna. 

32.  The  consolidation  or  cure  is  here  always  more 
speedy  than^  in  the  preceding  cases,  where  nature, 
with  the  same  amount  of  means  and  resources,  has 


165 

twice  the  quantum  of  labour  to  perform,  and  where 
she  supplies  her  deficiency  of  power,  by  the  greater 
length  of  the  time  which  she  employs.  In  general  the 
bone  is  united  by  the  twentieth  or  twenty-fourth  day. 

33.  When  the  fracture  exists  at  the  superior  part 
of  the  radius,  it  is  essential,  after  the  removal  of  the 
apparatus,  to  make  the  limb  very  frequently  perform 
all  its  natural  motions.  In  such  a  case,  indeed,  the 
parts  sometimes  swell,  become  stiff,  and  an  anchy- 
losis of  the  fore-arm  may  be  the  consequence,  as 
Ambrose  Pare  observes,  in  his  book  on  fractures, 
where  he  says  he  has  seen  many  accidents  of  this 
kind.  Galen  has  remarked  the  same  thing  before 
him.  The  following  case  reported  by  Jeo.  Dol**, 
confirms  the  truth  of  it. 

Case  IJ.  Jane  Rene  was  received  into  the  Hotel- 
Dieu,  in  consequence  of  a  fracture  of  the  upper  ex- 
tremity of  the  radius,  produced  by  a  fall  on  that  part, 
for  which  she  was  subjected  to  the  treatment  already 
described  (31).  The  apparatus  being  removed  at 
the  expiration  of  twenty-five  days,  the  consolidation 
was  perceived  to  be  complete.  The  motions  of  prona- 
tion and  supination  were  impracticable;  those  of 
flexion  and  extension  very  much  impeded.  The  pa- 
tient was  now  ordered  to  have  the  fore-aim  moved 
daily,  in  these  several  directions,  for  the  space  of  an 
hour,  and  this  space  was  even  increased  morning  and 
evening,  notwithstanding  the  pains  which,  at  first, 
accompanied  the  exercise.  On  the  eighth  day  prona- 
tion and  supination  could  already  be  performed  in  a 
small  degree;  they  became  more  and  more  free,  in 
proportion  as  the  exercise  of  the  limb  was  longei!" 
continued;  finally,  on  the  twenty-second  day  from 


166 

tlie  removal  of  the  apparatus,  the  patient  was  con- 
ducted, according  to  custom,  to  the  amphitheatre, 
where  all  the  pupils  witnessed  die  perfect  freedom  of 
the  motions. 

Case  III.  A  few  days  after  this,  a  man,  who  had 
left  the  Hotel- Dieu  about  eight  months  before,  while 
under  treatment  for  a  similar  fracture,  returned,  to  be 
the  subject  of  a  public  consultation  in  consequence 
of  a  different  disease. 

Desault,  on  interrogating  him,  learnt  from  him 
tliat  the  treatment  for  the  fracture  had  been  continued 
at  his  own  house  (31),  but  that,  when  the  apparatus 
was  removed,  no  motion  had  been  impressed  on  the 
limb,  and  that  die  surgeon  had  even  kept  it  in  a  sling. 
The  fore-arm  was  then  examined;  it  was  half  bent, 
constantly  in  a  state  of  pronation,  and  could  not,  by 
any  force,  be  brought  into  a  state  of  supination.  The 
motions  of  flexion  and  extension,  were  so  limited  as 
to  be  scarcely  sufficient  for  the  common  wants  of  the 
patient,  who,  under  proper  treatment,  might  have  - 
been  cured  like  the  preceding  one,  as  Desault  re- 
marked to  his  pupils  at  the  time. 

34.  The  patient  vi'^ho  was  the  subject  of  this  se- 
cond case,  was  sent  to  the  mineral  springs,  but  de- 
rived no  benefit  from  tlie  use  of  the  waters.  If  this 
were  a  proper  occasion,  I  could  mention  many  in- 
stances where  this  remedy,  so  highly  spoken  of  by 
many  physicians  of  the  present  time,  has  had  no  ef- 
fect, except  to  deprive  the  patient  of  more  efficacious 
means,  by  making  him  lose  that  time,  during  which 
exercise  frequently  repeated,  w^ould  have  effected 
a  cure,  but  which,  coming  too  late,  could  be  of  no 
avail. 


167 
FRACTURE  OF  THE  ULNA. 

OF   THE   CAUSES  AND  THE   SIGNS. 

35.  The  ulna,  less  frequently  broken,  in  general, 
than  the  radius,  scarcely  ever  suffers  alone  from  falls 
on  the  wrist  or  hand.  Most  commonly  its  fracture  is 
direct,  and  occurs,  in  particular,  in  cases  where  a  per- 
son in  falling,  extends  the  fore -arm  for  the  purpose 
of  supporting  himself,  and  strikes  its  internal  part 
against  some  resisting  body. 

The  division,  though  it  does  take  place  occasional- 
ly in  all  parts  of  the  bone,  occurs  most  frequently  near 
to  the  lower  end,  where  its  slender  size,  compared  to 
that  of  its  upper  end,  its  more  projecting  situation, 
and  its  thinner  covering  of  soft  parts,  act  as  predis- 
posing causes. 

36.  In  whatever  part  it  may  exist,  the  touch  must 
readily  detect  it,  when  the  fingers  are  drawn  along  the 
internal  surface  of  the  ulna,  which  lies  almost  imme- 
diately under  the  skin.  If  moved  in  contrary  direc- 
tions, the  fragments  will  also,  by  their  mobility  and 
crepitation,  disclose  the  nature  of  the  injury.  A  de- 
pression more  or  less  perceptible  is  observed  on  the 
internal  part  of  the  fore-arm,  produced  by  a  displace- 
ment of  the  fragments,  which  are  carried  towards  the 
radius,  more  particularly  of  the  inferior  fhigment,  as 
Petit  has  well  observed,  the  superior  one  remaining 
almost  immoveable. 


168 


XL 


OF   THE   REDUCTION,   AND   THE   MEANS   OF   MAIN- 
TAINING  IT. 

37.  The  reduction  does  not  differ  from  that  of 
the  radius  (31),  except  in  this,  that  the  assistant  who 
makes  the  extension,  must  place  the  hand  in  the  op- 
posite state,  namely,  that  of  abduction,  in  order  that 
the  fragments  may  be  brought  into  contact,  while 
the  surgeon  assists  in  this  process,  by  pushing  the 
broken  ends  of  the  bone  in  a  direction  opposite  to 
that  of  their  displacement. 

As  in  the  foregoing  case,  three  splints  are  suffi- 
cient for  the  appai'atus,  where  the  radius,  being  un- 
broken, performs  the  office  of  a  fourth. 

The  exercise  of  the  limb,  after  the  consolidation 
of  the  bone,  is  in  general  less  necessary  here,  than  in 
fractures  of  the  radius  (34),  because  the  ulna,  being 
an  immoveable  point  of  support  for  the  motions  of 
rotation,  concm's  in  them  only  in  a  passive  manner. 

FRACTURE  OF  THE  OLECRANON. 
^XII. 

REMARKS  ON   THE   OLECRANON. 

38.  The  ulna  is  surmounted,  at  its  upper  end,  by 
a  considerable  appendix,  curved  before,  where  it  cor- 
responds to  the  articulation  of  the  fore-arm,  and  is 
covered  with  cartilage;  convex  behind,  where  thercj 


169 

is  nothing  to  separate  it  from  the  external  integu- 
ments, and  is  attached  at  its  upper  end  to  the  strong 
tendon  of  the  triceps  muscle,  which  appears  to  be  in- 
corporated with  it.  This  appendix  resembles  greatly, 
in  its  structure,  form,  and  uses,  the  rotula,  from 
which  it  would  differ  in  nothing,  if  the  inferior  liga- 
ment of  the  latter  were  ossified,  so  as  to  form  a  bony 
continuity  between  it  and  the  tibia.  It  is  exposed  to 
fi^actures,  perfectly  similar  to  those  of  the  rotula,  but 
^vhich  differs  so  essentially  from  the  other  fractures  of 
the  ulna,  as  to  call  for  a  separate  examination. 

39.  The  ancients  appear  to  have  had  but  little 
knowledge  of  fractures  of  the  olecranon,  respecting 
which  they  have  transmitted  nothing  to  us,  unless 
with  Dalechamps,  we  find  cause  to  recognize  a  refer- 
ence to  this  affection  in  the  following  passage  of  Paul 
of  Egina :  Cubitus  frangitur, . .  circa  partem  ad  cubiti 
gilbum. 

Most  of  the  modems  have  spoken  of  it  only  in  a 
vague  manner;  no  one  has  described  with  accuracy 
the  signs  which  characterize  itj  and  few  have  given 
satisfactory  ideas  on  its  treatment.  Petit  has  not 
spoken  of  it  separately,  and  Duverney,  who  concludes 
with  it  his  article  respecting  fractures  of  the  fore-arm, 
has  but  imperfectly  described  for  it  a  bandage  "which 
is  in  itself  equally  imperfect.  Bell  does  not  give  us, 
on  this  point,  an  exposition  of  either  his  opinions  or 
his  practice. 

Yet  this  fracture  is  by  no  means  so  rare  as  to  jus- 
tify the  silence  of  authors,  and  its  treatment  merits  a 
degree  of  attention  beyond  that  which  is  requisite  in 
most  other  fractures. 

23 


170 
§  XIII. 

OF   THE  VARIETIES  AND   CAUSES. 

40.  The  olecranon  suffers  fractures  at  its  base  and 
at  its  summit,  but  more  frequently  in  the  first,  than  in 
the  second  situation.  The  division,  though  very 
generally  transverse,  is  sometimes  oblique.  Desault 
met  with  an  instance  of  an  oblique  fracture  of  the  ole- 
cranon in  a  man,  who  had  sustained  a  violent  blow 
on  his  fore-arm  from  a  club. 

41.  The  causes  which  produce  itai'€,  either  mus- 
cular action,  a  circumstance  that  very  rarely  occurs, 
or  the  direct  action  of  external  bodies,  which  is  by 
far  the  most  common  case.  The  reverse  of  this  is 
tine  with  regard  to  fractures  of  the  rotula,  which  are 
almost  always  produced  by  the  contraction  of  the 
muscles  attached  to  that  bone. 

42.  The  olecranon  has  been  at  times  separated 
from  the  ulna,  by  the  act  of  throwing  a  stone  witli 
great  force.  In  such  cases,  the  fracture  has  been  pro- 
duced by  the  immediate  action  of  the  triceps  muscle. 
This  is  tlie  first  mode  of  division. 

The  second  occui's  when  a  violent  blow  is  receiv- 
ed on  the  elbow,  or,  more  particularly,  from  falls  on 
that  pait  r  for  example,  if,  when  descending  a  flight 
of  stairs,  our  heel  slip  and  we  fall  backwards,  the  arm 
is  suddenly  tlirown  behind  to  save  the  body.  In  such 
a  case,  the  olecranon  striking  forcibly  against  one  of 
the  steps,  and  being  pressed  between  it  and  the  weight 
of  the  body,  is  broken.  In  this  way  was  the  disease 
produced  in  a  majority  of  the  patients  attended  by 
Desault  for  fi-actures  of  the  olecranon. 


171 
§  XIV. 

OF   THE   SIGNS. 

43.  We  meet  here  with  the  same  appearances  and 
state  of  things,  which  constantly  occur  in  fractures  of 
the  rotula.  The  triceps  extensor,  finding  no  longer  in 
the  continuity  or  sound  state  of  the  ulna,  a  resistance 
to  its  contractions,  draws  upwards  the  short  fragment 
to  which  it  adheres,  produces  between  it  and  the 
lower  one  an  interval  more  or  less  perceptible,  and 
gives  rise  to  the  greater  part  of  the  other  character- 
istic signs  of  the  affection :  these  are,  1st,  An  inter- 
val or  space  between  the  fragments,  corresponding  to 
the  posterior  part  of  the  articulation.  This  interval 
may  be  increased  at  pleasure,  by  increasing  the  flexion 
of  the  fore-arm,  or  by  making  the  patient  contract  the 
triceps  muscle,  and  may  be  again  diminished,  by 
bringing  the  arm  into  a  state  of  extension :  2dly,  An 
inability  in  the  patient  to  extend  the  fore-arm  spon- 
taneously, which  is  the  necessary  result  of  the  separa- 
tion of  die  triceps  from  the  ulna:  3dly,  A  constant 
semiflexion  or  half-bent  state  of  the  fore-arm,  pro- 
duced by  the  contractions  of  the  biceps  and  brachialis 
intemus  muscles,  to  which  no  antagonists  ai'e  now 
opposed:  4thly,  An  elevation,  more  or  less  percepti- 
ble, of  the  olecranon  above  the  condyls,  which,  on  the 
contrary,  rise  above  it,  when,  in  a  natural  state  of  the 
parts,  the  fore-arm  is  half-bent:  5thly,  A  facility  of 
moving  the  upper  fragment  in  every  direction,  without 
communicating  any  motion  to  the  ulna;  6thly,  A 
peculiar  sensation  experienced  by  the  patient,   to 


172 

^vhom  it  seems,  when  he  makes  an  effort  to  extend  the 
fore-arm,  as  if  some  body  or  substance  were  detached 
or  broken  off  from  his  elbow,  and  carried  upwards. 
The  patient  may  realize  the  justness  of  this  sign,  by 
comparing  it  with  what  he  feels  on  attempting  to  ex- 
tend the  opposite  fore-arm,  placed  in  the  same  posi- 
tion. 

44.  If  to  these  signs  be  added  the  circumstances 
which  accompany  the  accident,  the  severe  pain  that 
is  always  felt,  the  crack  which  is  sometimes  heard 
by  the  patient,  and  the  possibility  of  producing  a  per- 
ceptible crepitation,  by  rubbing  the  fragments  in 
contrary  directions,  after  having  first  brought  them 
together,  it  will  be  difficult  to  be  mistaken  respecting 
the  existence  of  the  fracture,  which  indeed  the  sw^ell- 
ing  of  the  part  alone  can  conceal  from  the  practi- 
tioner, if,  as  sometimes  happens,  it  be  consider- 
able. But  then,  being  soon  dispersed,  either  spon- 
taneously, or  by  the  action  of  discutients,  it  leaves  the 
accident  unmasked,  accompanied  by  the  signs  just 
enumerated. 

45.  To  the  swelling  is  oftentimes  added,  an  echy- 
mosis  more  or  less  considerable,  when  the  accident 
has  been  produced  by  a  fall  on  the  elbow.  But  by 
this,  no  change  is  effected  in  the  essential  characters, 
which  are  always  sufficient  to  distinguish  a  fracture 
from  a  luxation  backwards,  with  which  it  has  been 
sometimes  confounded,  as  appears  from  many  ex- 
amples recorded  in  different  works. 


173 
§  XV. 

OF   THE    PROGNOSIS. 

46.  I  will  not  dwell  on  the  question,  so  much 
agitated  of  late,  namely,  whether  or  not  the  olecranon 
be  susceptible  of  consolidation  or  reunion.  Already 
has  it  been  hundreds  of  times  answered  by  experi- 
ence. What  could  theory  add  to  the  conviction  al- 
ready impressed  on  us  from  that  quarter?  It  was  by 
exhibiting  to  the  croud  of  pupils  who  attended  his 
clinical  lectures,  fractures  of  this  kind  perfectly  re- 
united, that  Desault  refuted  the  weak  arguments,  of 
the  periosteum  not  being  able,  in  consequence  of  not 
covering  the  anterior  surface  of  the  olecranon,  to  pro- 
duce a  union  between  its  fragments,  of  the  synovia 
mixing  with  the  matter  of  callus,  diluting  it,  weak- 
ening it,  preventing  it  from  becoming  sufficiently 
hard  for  the  purpose  of  reunion,  &c.  We  will  only 
observe,  that  these  ideas  are  borrowed  from  a  theory 
which  modem  experiments  have  proven  to  be  un- 
founded, and  which,  were  it  true,  would  be  applied 
in  the  present  case  quite  unphilosophicaliy,  since  it 
would  deny  to  certain  parts  of  man  the  power  or 
property  of  restoration  or  being  healed,  a  property 
common  to  all  the  component  parts  of  beings  endowed 
with  life,  and  which  even  constitutes  one  of  their  es- 
sential and  discriminative  characters. 

47.  Is  the  consolidation  of  the  olecranon  effected 
in  the  same  mode  as  in  other  bones?  The  observations 
of  many  practitioners.  Camper  in  particular,  seem  to 
prove  that  a  ligamento-cataloginous  substance  is  al- 


174 

ways  the  medium  of  the  union  of  fragments.  De- 
sault  once  found  this  substance  in  a  corpse,  but  it 
was  in  a  case  where  the  fracture  had  been  improperly 
treated,  and  where,  of  course,  no  inference  could  be 
drawn  with  regard  to  ordinary  cases. 

48.  But  of  what  import  to  us  are  the  means 
which  nature  employs?  The  indication  is  still  the 
same.  The  fragments  must  be  always  kept  in  con- 
tact, that  the  reunion  may  be  immediate,  and  that, 
as  David  observes,  in  his  memoir  on  motion  and  rest 
in  surgical  diseases,  the  apophysis  may  not,  by  be- 
coming too  long  in  consequence  of  the  space  occu- 
pied by  the  callus,  impede  the  extension  of  the  fore- 
arm on  the  OS  humeri. 

^  XVI. 

OF   THE   MEANS  OF   CONTACT  BETWEEN   TH£ 
FRAGMENTS. 

49.  There  are  no  fi'actures,  the  treatment  of  which 
demands  more  attention,  or  is  surrounded  with  more 
difficulties,  than  that  of  the  olecranon.  Here  art  can- 
not, as  in  the  thigh,  and  the  clavicle,  oppose  to  the 
ever  active  po^ver  of  the  natural  muscles,  a  constant 
resistance  produced  by  the  action  of  a  kind  of  artifi- 
cial muscle,  consisting  in  permanent  extension.  The 
superior  fragment,  being  too  small  to  give  any  pur- 
chase to  extending  forces,  can  be  only  pushed  down^ 
wards,  and  kept  in  that  position  with  a  greater  or  less 
degree  of  stability  and  firmness,  while  the  ulna,  so  to 
spealc,  is  drawn  to  meet  it.  Whence  it  follows,  that 
extension  here  is  of  little  use,  and  that  it  is  chiefly  by 


175 

position  or  attitude,  aided  by  a  judicious  conforma- 
tion, tliat  the  reduction  is  effected. 

50.  The  position  has  varied  in  the  hands  of  dif- 
ferent practitioners.  Some  have  proposed  that,  in 
wliich  the  fore-arm  is  half-bent,  so  as  to  form  a  right 
angle  with  the  os  humeri.  The  example  mentioned 
by  David,  is  not  the  only  one  where  recourse  has 
been  had  to  this.  But,  by  rejecting  the  general 
principle  respecting  the  reunion  of  parts,  which  re- 
quires them  to  be  kept  in  perfect  contact,  this  mode 
is  exposed  to  a  double  inconvenience.  The  reunion 
is  extremely  slow  in  being  accomplished,  and,  when 
ultimately  obtained,  is  accompanied  by  the  loss  of  one 
part  of  the  movements  of  the  limb,  in  consequence 
of  the  length  of  the  callus.  This  callus  must  neces- 
sarily fill  up  the  whole  space  that  intervened  between 
the  fragments  during  the  treatment,  and  being  thus 
added  to  the  natural  extent  of  the  olecranon,  length, 
ens  this  appendix  to  such  a  degree,  that,  in  extend- 
ing the  fore-arm,  its  summit  or  upper  end  comes  too 
soon  into  contact  with  the  cavity  in  the  os  humeri 
destined  to  receive  it. 

51.  This  practice  appears  to  have  been  chiefly 
owing  to  an  opinion  then  in  existence,  that  an  anchy- 
losis being  the  necessary  consequence  of  the  fracture, 
it  was  proper  to  place  the  arm  in  that  position  in 
which  it  would  be  most  likely  to  be  still  of  some 
service. 

52.  We  must  not,  however,  by  throwing  the 
fore-arm  into  the  greatest  possible  degree  of  exten- 
sion,  allov/  it  to  be  drawTi  into  the  opposite  extreme. 
From  this  en-or  the  same  inconveniencies  would  re- 


176 

suit.  In  such  a  case,  should  the  fragments  touch 
each  other,  and  press  too  hard  at  their  posterior 
edges,  they  must  inevitably  leave  an  intervening  va- 
cuity or  space  between  their  anterior  edges.  Hence 
a  greater  tliickness  of  callus  on  the  one  side  than  on 
the  other,  and  consequently  an  impediment  more  or 
less  troublesome  in  the  motions  of  the  joint.  If  the 
inferior  fragment  do  not  touch  the  superior  one,  it 
sinks  into  the  olecranon  cavity,  leaves  the  other  be- 
hind it,  and  hence  another  source  of  irregularity  in 
the  consolidation. 

53.  Between  these  two  extremes  (50  and  51),  it 
remains  to  choose  a  middle  course,  and  that  position 
will  be  best,  in  which  the  fore-arm  shall  be,  so  to 
speak,  in  a  state  between  semi-flexion  and  extension. 
By  this  the  fragments,  being  brought  into  perfect 
contact,  will  experience  no  obstacle  to  a  reunion, 
which  will  be  therefore  both  speedy  and  uniform. 

54.  But  it  w^ould  be  useless  to  place  the  limb  in 
a  proper  position,  if  no  means  were  made  use  of  to 
retain  it  there.  Being  immediately  submitted  to  the 
action  and  influence  of  a  multitude  of  causes,  it  will 
lose  its  position,  and  the  work  of  nature  being  inter- 
rupted, the  consolidation  will  be  retarded. 

Hence  appears,  both  the  necessity  of  placing  a 
solid  body,  as  Desault  did,  before  the  whole  of  the 
limb,  to  prevent  its  flexion,  and  the  insufiiciency  of 
the  apparatus  proposed  by  Duverney  and  others,  who 
directed  to  lay  a  thick  compress  on  the  fracture,  to 
suiTOund  the  elbow  then  by  a  circular  one,  to  secure 
the  v/hole  by  a  kind  of  figure  of  8  bandage,  similar 
to  that  used  in  blood-letting,  and,  finally,  to  place  the 
limb  on  a  pillow,  without  further  precaution. 


177 

55.  Position  alone  evidently  acts  only  on  the 
lower  fragment,  which  it  directs  towards  the  upper 
one.  But  it  is  also  necessary  to  draw  the  upper  frag- 
ment towards  the  lower  one,  and  fix  it  there,  and  this 
is  certainly  the  most  difficult  point;  because,  the 
triceps  muscle  having  a  constant  tendency  to  con- 
tract, opposes  its  action  to  the  approximation  of  the 
fragments,  and  indeed  prevents  it,  if,  as  in  the  means 
usually  proposed  and  adopted,  the  pieces  of  the  ban- 
dage glide  easily  over  each  other. 

56.  These  considerations  determined  Desault  to 
search  for  some  means  which,  being  more  efficacious 
than  those  already  in  use,  might  better  fulfil  the  indi- 
cations of  the  fracture.  He  accordingly  invented  the 
apparatus  which  we  are  about  to  describe;  some 
ideas  of  this  apparatus  are  indeed  borrowed  from 
other  bandages.  The  success  which  attended  the 
use  of  it  at  the  Hotel-Dieu,  will,  without  doubt,  in- 
troduce it  generally  into  rational  practice,  where  the 
insufficiency  of  the  old  forms  of  apparatus  is  acknow- 
ledged. 

1st,  The  fore-arm  being  placed  in  the  position  alrea- 
dy directed  (53),  two  assistants  retain  it  in  that  situa- 
tion, while  the  surgeon  applies  on  its  lower  part  the 
end  of  a  roller  five  or  six  yards  long,  and  about  four 
inches  wide,  wet  with  some  discutient  liquid,  making 
with  it,  at  first,  one  or  two  circular  turns  to  fasten  it. 
Then  ascending  from  below  upwards,  he  covers  the 
whole  of  the  fore-ai^m  with  oblique  and  reverse  turns 
moderately  tight. 

2dly,  Having  arrived  at  the  joint,  he  stops,  and 
makes  an  assistant  draw  the  skin  of  the  elbow  up- 

24 


178 

wards,  lest,  being  loosened  and  wrinkled  by  means 
of  the  extension,  it  might  get  between  the  fragments, 
and  create  an  impediment  to  their  remiion.   Then, 
taking  hold  of  the  olecranon,  he  draws  it  down  to- 
wards the  ulna,  and  passes  behind  it,  as  a  substitute 
for  his  fingers  which  have  hitherto  kept  it  firmly  fix- 
ed, a  cast  of  the  roller,  which  he  brings  from  the  an- 
terior part  of  the  fore-arm  above  the  elbow.  Descend- 
ing again  with  the  roller  along  the  external  side  of 
the  ai^m,  and  returning  across  the  anterior  part,  he 
pursues  again  the  same  course,  so  as  to  make  the 
casts  of  the  roller  lie  on  each  other,  and  surround  the 
elbow  like  a  kind  of  figure  of  8. 

3dly,  The  surgeon  proceeds  now  by  oblique 
turns,  to  the  upper  part  of  the  ai'm,  where  he  fixes 
the  roller,  by  a  circular  turn,  and  gives  it  into  the 
hand  of  an  assistant.  He  next  applies  along  the  arm 
and  fore-arm,  a  splint  very  strong,  but  a  little  bent  at 
the  place  vdiich  corresponds  to  the  joint,  in  order  to 
prevent  too  great  an  extension  of  the  limb :  then, 
resuming  the  roller,  he  employs  it,  in  a  descending 
direction,  to  secure  the  splint. 

4thly,  The  apparatus  being  applied,  the  limb  is 
placed  on  a  pillow,  so  as  to  be  equally  supported 
throughout  its  length,  and  is  protected  by  hoops  from 
the  weight  of  the  bed-clothes. 

57.  To  the  bandage  which  we  have  just  describ- 
ed, Desault  added  formerly  a  strip  of  linen,  to  be 
placed  all  along  the  posterior  part  of  the  arm,  se- 
cured first  at  its  upper  end  by  circular  casts,  which 
began  above;  this  strip  was  secured  afterwai'ds  by 
oblique  casts,  as  far  as  to  the  place  where  it  met  the 


179 

olecranon,  separated  from  the  ulna.  Here,  the  sur= 
geon  quitting  the  roller,  took  hold  of  the  bit  of  linen, 
and  drew  it  downwards,  and  along  with  it  the  circular 
casts  of  the  roller,  together  with  the  muscles  on  which 
these  casts  were  applied,  and  also  the  fragment  which 
the  muscles  drew  upwards.  An  assistant  then  secur- 
ed it  here,  while  the  surgeon,  after  having  made  some 
casts  in  form  of  the  figure  of  8,  descended  to  the  in- 
ferior part  of  the  fore-arm,  where  the  end  of  the  strip 
was  made  fast  by  tight  circular  turns.  (See  fracture 
of  the  rotula.) 

58.  The  intention  of  this  additional  piece  of  ap- 
paratus, was  to  draw  down  the  superior  fragment,  to 
prevent  the  circular  casts  of  the  roller  fi:om  separat- 
ing by  their  relaxation,  and,  by  that  means,  to  retaia 
the  fragments  in  apposition.  But,  on  the  one  hand, 
may  not  the  superior  fragment  be  di'awn  by  the  hand, 
as  well  as  by  a  roller  employed  for  the  purpose  ? 
And,  on  the  other,  if  the  circular  casts  of  the  roller 
be  liable  to  become  relaxed,  why  not  the  strip  of  linen 
also?  These  considerations  induced  Desault  to  lay 
it  aside,  and  use  the  bandage  in  tit©  form  just  de- 
scribed. 

59.  The  advantages  it  offers  ^e  far  from  being 
equivocal.  1st,  The  limb  is  kept  in  a  state  of  invari- 
able extension  by  the  anterior  splint,  and,  on  this  ac- 
count, there  can  be  no  displacement  cm  the  part  of 
the  inferior  fragment.  2dly,  The  bandage,  which  ac- 
curately envelopes  the  whole  limb,  restrains  the  action 
of  the  muscles  by  compressing  them,  and  prevents 
in  part  the  contractions  of  the  triceps ;  while  the  casts 
in  the  form  of  the  figure  of  8,  applied  with  skill  and 


180 

precision,  hold  down  the  superior  fragment,  and  ren- 
der it  difficult  for  it  to  be  displaced*  3dly,  Without 
the  application  of  a  roller  over  the  whole  limb,  a  swel- 
ling, more  or  less  considerable,  would  probably  be 
the  effect  of  the  constriction  at  the  elbow,  which  must 
necessarily  be  somewhat  tight,  because,  as  the  turns 
of  the  roller,  in  form  of  the  figure  of  8^  act  on  the 
olecranon  obliquely,  if  they  be  too  loose,  they  will 
slip  and  not  perfonn  the  office  of  retention. 

60.  Like  all  kinds  of  apparatus  composed  of  rol- 
lers, this  ought  to  be  frequently  examined,  lest,  by 
becoming  relaxed,  it  should  not  make  sufficient  re- 
sistance to  the  triceps,  which  is  always  disposed  to 
dra*w  itself  upwai'ds.  There  can  be  no  period  fixed 
on  for  the  reapplication  of  the  apparatus;  the  moment 
it  begins  to  become  slacks  it  ought  to  be  renewed: 
three  or  four  times  during  the  course  of  the  treatment 
are  generally  sufficient.  Should  a  considerable  swell- 
ing give  reason  to  suspect  that  the  constriction  is  toer 
great,  it  will  be  necessary  to  remove  the  bandage  in 
order  to  apply  it  anew. 

61.  The  period  necessary  for  the  reunion  of  frac- 
tures of  the  olecranon  varies,  according  as  the  bandage 
is  more  or  less  exactly  kept  in  its  place.  Among  ten 
cases  of  this  kind,  collected  in  the  Hotel- Dieu,  four 
united  in  twenty-four  days,  three  in  twenty -eight, 
and  three  in  thirty-two.  Hence,  taking  the  mean  term, 
all  other  circumstances  being  alike,  the  process  of 
cure  requires  about  twenty- six  days. 

62.  When  this  is  completed,  it  is  necessary  to 
impress  on  the  limb  motions  of  flexion  and  exten- 
sion, gradually  increased  every  day.  This  is,  as  Da- 


181 

vid  properly  observes,  the  most  certain  method  of 
avoiding  a  stiffness,  and  even  an  anchylosis,  too  often 
the  consequence  of  this  fracture. 

63.  But  that  illustrious  practitioner,  in  recom- 
mending this  salutary  remedy,  has  erred  with  regard 
to  the  mode  in  which  it  operates.  To  consume,  by- 
degrees,  a  superabundant  callus  in  the  interior  of  the 
articulation,  and  thus  reduce  it  to  a  level  with  the  ar^ 
ticulating  surfaces,  is  not,  as  he  conceives,  the  effect 
which  these  motions  produce.  This  opinion,  founded 
on  the  ancient  doctrine  of  an  osseous  juice,  is  refuted 
by  the  dissection  of  many  bodies  of  patients  that  died 
during  the  treatment,  and  in  which  Desault  discover- 
ed no  trace,  either  of  an  effusion  of  osseous  juice, 
during  the  reunion,  or  of  its  superabundance  after 
this  reunion  had  been  completed. 

The  exercise  communicated  to  the  limb,  appears 
to  act  principally  by  removing  the  congestion  of  the 
tendons  and  membranes  surrounding  the  joint,  which, 
being  at  first  irritated  by  the  fracture,  ai^e  thrown  into 
a  state  of  engorgement ;  and  further  by  dissipating 
a  kind  of  numbness  which  affects  the  muscles  after 
they  have  remained  too  long  in  a  state  of  rest. 

64.  But  whatever  may  be  its  mode  of  action,  it 
ought  to  be  gradually  increased,  according  to  the 
state  of  the  parts,  and  continued  for  at  least  twenty 
days,  a  period  sufficiently  long  to  restore  to  the  limb, 
in  general,  its  natural  motions. 

65.  It  is  seldom  that  after  this  methodical  treat- 
ment, the  patient  is  exposed  to  an  anchylosis,  a  thing 
inevitable  in  such  cases,  according  to  most  authors, 
A  celebrated  surgeon,  believing  the  long  continued 


182 

extension  of  the  fore-arm  to  be  the  cause  of  this  acci- 
dent, has  advised  here  to  abandon  every  kind  of  ban- 
dage, and  to  commit  the  cure  entu-ely  to  nature^ 
But  this  doctrine,  contrary  to  the  general  principles 
of  the  reunion  of  divided  parts,  has  not  in  its  favour 
the  result  of  experience,  which  proves  that,  under 
such  neglect,  the  stiffness  in  the  parts  near  to  the  joint 
is  always  as  great  as  in  other  cases,  that  the  reunion 
is  more  tedious  and  more  deformed,  and  that  some- 
times it  cannot  be  accomplished  at  all.  The  analogy 
of  the  inconveniences  and  disadvantages  attributed  to 
the  method  of  Foubert,  in  fractures  of  the  neck  of  the 
OS  femoris,  constitutes  another  argument  against  this 
method,  which  is  now  almost  entirely  abandoned. 

66.  To  the  cases  already  published,  proving  the 
success  of  that  which  we  have  proposed,  let  us  add 
one  more,  reported  by  Maublanc. 

Case  IV.  Silvan  de  la  None,  aged  thirty,  fell  on 
his  elbow,  having  his  fore-arm  bent,  while  the  shoul- 
der of  the  same  side  supported  a  heavy  load.  Acute 
pains  at  the  instant  of  the  fall ;  a  sudden  inability  to 
extend  the  fore-arm ;  a  considerable  swelling  appears 
almost  immediately,  around  the  joint;  and  a  superfi- 
cial echymosis  at  the  hind  part. 

During  the  night  the  pains  were  augmented,  the 
swelling  increased,  and,  on  the  day  following,  Febru- 
ary 9th,  1791,  the  patient  was  received  into  the  Hotel- 
Dieu. 

From  the  presence  of  the  signs  formerly  menti- 
oned (43),  Desault  recognized  the  fracture,  and  ap- 
plied the  apparatus  (56),  notwithstanding  the  swelling 
and  echymosis,  persuaded  that  the  compression  made 


183 

by  this  apparatus  on  the  tumefied  parts,  was  the  most 
effectual  mode  to  remove  the  enlargement. 

Next  day,  pains  almost  gone ;  swelling  diminish- 
ed; on  the  fifth  day,  the  bandage  become  loose,  by 
the  almost  entire  disappearance  of  the  swelling;  a 
new  application  of  it ;  the  joint  wet  frequently  with 
vegeto-mineral  water. 

Seventh  day,  usual  regimen  allowed;  ninth  day, 
a  slightly  bilious  disposition;  evacuants  somevv'hat 
active  administered,  to  remove  it. 

Thirteenth  day,  a  third  application  of  the  appa- 
ratus ;  echymosis  entirely  gone. 

Thirtieth  day,  the  consolidation  complete;  the 
apparatus  laid  aside ;  from  this  time  motions  gradu- 
ally impressed  on  the  limb. 

Fifty-eighth  day,  the  patient  discharged,  free  in 
all  his  motions,  except  a  little  stiffness,  which  exer- 
cise will  soon  remove.  Since  that  time,  it  has  been 
understood  that  the  limb  had  completely  recovered  its 
natural  functions. 


184 
MEMOIR  IX. 

ON   THE   LUXATION   OF   THE   FORE-ARM. 


1.  Th  E  solidity  and  security  of  joints  are  increased 
in  proportion  as  the  extent  of  their  motions  is  dimi- 
nished. This  inverse  proportion  of  these  two  proper- 
ties to  each  other,  is  in  a  particular  manner  remai^k- 
able  in  the  upper  extremities,  where  the  comiexion 
of  the  humerus  with  the  scapula,  of  the  fore-arm  with 
the  humerus,  and  of  the  bones  of  the  wrist  among 
themselves,  appear,  in  regular  gradation,  to  acquire 
the  one  as  they  lose  the  other:  hence,  their  predispo- 
sition to  luxations  is  extremely  different.  We  will 
examine  those  to  which  the  fore-arm  is  subject. 

2.  An  angulai'  ginglymus  unites  to  the  humerus 
tiie  bones  of  the  fore-ann,  wliich  are  again  connected 
with  each  other  by  a  double  lateral  ginglymus.  Emi- 
nences and  depressions,  reciprocally  receiving  and 
received,  constitute  the  first  kind  of  articulation, 
where,  proceeding  fi^om  without  inwardly,  we  find, 
1st,  the  small  head  of  the  humerus,  entering  or  rather 
joining  the  upper  articulai'  ca\'ity  of  the  radius,  which 
moves  on  it:  2dly,  the  external  groove  of  the  hume- 
rus, receiving  the  rim  of  the  same  cavity  of  the  radius: 
3dly,  a  projection  which,  rising  fi'om  the  external 
edge  of  the  coronoide*  cavity,  extends  to  the  corres^ 
ponding  edge  of  that  of  the  olecranon,  and  is  received 

*  Not  generally  named  in  English  works  of  anatomy. 


185 

into  the  external  depression  of  the  sigmoid  cavity:* 
^-thly,  the  large  groove  of  the  humerus,  receiving  the 
middle  eminence  of  this  same  cavity:  5thly,  a  con- 
siderable projection,  obliquely  applied  to  the  internal 
depression  which  receives  it. 

3.  These  numerous  connexions  secure  the  solidi- 
ty of  the  joint,  which  is  still  farther  strengthened  be- 
fore by  the  coronoid  apophysis,  together  with  the 
fleshy  and  tendinous  extremities  of  the  biceps,  and 
brachialis  muscles,  and  by  the  olecranon  behind;  at 
the  inferior  part,  by  the  anconeus;  on  the  sides  by 
two  ligaments  which  descend  from  the  two  tuberosi- 
ties, and  strong  muscular  facile  running  from  the 
same  parts.  The  whole  articulation  is  also  surround- 
ed by  a  thick  capsule,  strengthened  by  numerous 
accessory  fibres.  With  such  powers  of  resistance, 
how  can  this  joint  suffer  a  luxation?  Yet  next  to  that 
of  the  OS  humeri,  it  is  perhaps  most  frequently  sub- 
ject to  this  accident. 

§  II. 

OF   THE   KINDS   AMD   CAUSES   OF   DISPLACEMENT. 

4.  Writers  have  admitted  in  general  four  kinds  of 
displacement ;  backward,  forward,  outward,  and  in- 
ward. But  all  these  are  not  alike  frequent,  as  is  prov- 
ed by  experience,  and  demonstrated  by  the  relative 
situation  of  the  parts. 

5.  In  a  backward  direction  the  olecranon  and 
the  radius  may  pass  up  behind  the  humerus,  as  the 

*  JEchancrure  si^moide. 
25 


186 

Coronoid  apophysis  offers  but  little^esistance  in  con- 
sequence of  its  slight  curvature.  On  the  other  hand, 
the  kind  of  hook  formed  by  the  olecranon,  prevents 
it  and  the  radius  from  passing  before  the  lower  arti- 
culating extremity  of  the  humeiiis,  and  therefore, 
without  a  fi-acture  of  the  olecranon,  a  luxation  in 
that  direction  is  impracticable  :  at  the  sides,  the  two 
lateral  ligaments,  but  more  paiiiculai'ly  the  recipro- 
cal joining  or  interlocking  of  the  uneven  articulating 
surfaces,  present  almost  insurmountable  obstacles 
to  luxations  laterally.  Whence  it  follows,  that  luxa- 
tion backward  is  much  more  frequent  than  the  others; 
compai'ed  to  lateral  luxations,  it  is,  at  least,  in  the 
proportion  of  ten  to  one:  with  luxations  fonvard, 
no  comparison  can  be  made ;  neither  Petit  nor  De- 
sault  having  ever  met  with  such. 

6.  An  external  force  produces  the  Vvhole  of  these 
luxations,  but  according  to  each,  this  force  must 
vary.  In  a  fall  sideways,  suppose  the  hand  be  applied 
to  the  ground,  with  the  ai'm  extended,  to  save  the 
body.  It  is  evident  that  the  resistance  of  the  ground 
will  tend  lo  make  the  bones  of  the  fore-arm  pass  up- 
w^ards  over  the  humerus,  while  the  weight  of  the 
bod}'  pushing  that  bone  downward  and  forward,  will 
make  it  glide  over  the  coronoid  apophysis.  Thus, 
tlie  capsule,  being  distended  before  by  the  humerus, 
andbeliindby  the  bones  of  the  fore-arm,  w^ill  give 
way  in  one  or  the  other  place,  or  in  both,  as  Desault 
obser^^ed  in  a  man,  v\^ho  fell  on  his  side,  as  he  was 
caiTying  a  heavy  load :  the  weight  of  the  body  in- 
creased by  the  load,  had  such  an  effect,  that  the 
bones  overlapped  each  other  nearly  two  inches. 


187 

7.  It  appears  from  this,  that  a  state  of  extension 
is  the  position  most  favourable  to  a  displacement 
backwards;  a  doctrine  by  no  means  conformable  to 
that  of  most  practitioners,  who  consider  a  state  of 
flexion  as  necessary  to  the  accident.  But,  then,  in 
what  direction  should  the  fall  take  place,  in  order 
that  the  olecranon  may  pass  upwards  ?  Applied  as  ii 
is  against  the  side  of  the  cavity  that  receives  it  when 
the  arm  is  extended,  would  not  this  apophysis  pre- 
vent such  passage  ?  Whatever  may  be  the  mode  of 
displacement,  the  olecranon,  in  passing  upward  and 
backward,  may  incline  a  little  to  the  one  or  the  other 
side. 

8.  I  have  already  said,  that  without  a  fracture  of 
the  olecranon,  no  luxation  forward  can  occur  (5). 
But  what  cause  can  act  with  sufficient  power  on  the 
parts  to  produce  both  accidents  at  the  same  time  ? 
It  would  be  necessary  that  a  fall  which  had  produced 
a  fracture  should  be  succeeded  by  another  fall;  but 
in  such  a  case,  the  fore-arm  whould  behalf-bent,  and 
it  is  in  a  state  of  extension  alone  (7)  that  the  luxation 
can  take  place. 

9.  Lateral  luxations,  that  is,  luxations  at  the  sides 
have  been  divided  into  complete,  when  the  two  arti- 
cular ranges  of  the  arm  and  fore -arm,  have  lost 
their  connexion  entirely,  and  incomplete,  when  only 
one  bone  or  one  part  of  a  bone  has  been  separated 
from  its  natural  connexion  with  the  humerus.  But 
what  cause  can  act  with  sufficient  force  to  pro- 
duce the  first  kind  of  luxation,  namely,  that  which 
is  complete  ?  In  such  an  accident  so  great  ^vould  be 
the  extent  of  the  -wTCck  and  ruin  of  the  part,  that 


188 

without  doubt  amputation  would  be  the  ordy  re- 
source. 

10.  The  second  kind  of  lateral  displacement  is  the 
result  of  a  stroke  which  forces  violently  the  extre- 
mity of  the  fore-aiTQ  outward  or  inward.  A  footman, 
says  Petit,  in  falling  from  a  carriage,  had  his  arm 
entangled  between  the  spokes  of  the  wheel,  and  suf- 
fered in  consequence  a  luxation  outwards.  Another 
produced  one  inwardly,  by  being  thrown  from  his 
horse,  and  falling  with  his  arm  under  him,  on  rou^ 
ground.  Strokes  of  this  kind  may,  as  that  author  re- 
marks, vary  in  a  singular  manner.  But,  in  general, 
in  all  of  them,  the  fore- arm  must  represent  a  lever  of 
the  first  kind,  where  the  power  acts  on  the  end  next 
the  hand;  the  resistance  being  in  the  joint,  and  the 
fulcrum  in  the  middle. 

§  III. 

GF  THE   SIGNS. 

11.  To  form  an  idea  of  the  signs  or  appearances 
of  a  luxation  backwards,  let  us  examine,  for  a  mo- 
ment, the  natural  situation  of  the  olecranon,  and 
the  condyls  of  the  humerus.  As  these  eminences 
are  easily  felt  under  the  skin,  a  knowledge  and  recol- 
lection of  their  situation  will  serve  as  a  standard  of 
comparison,  to  judge  of  the  changes  they  experience 
in  a  luxation.  When  the  fore-arm  is  extended,  the 
olecranon  is  on  a  level  with  the  internal  condyl, 
and  a  little  above  the  external  one.  In  a  state  of 
flexion,  it  descends  below  this  level,  and  is  then  far- 
ther below  the  internal  than  the  external  condyl.    In 


189 


either  situation,  it  is  nearer  to  the  first  than  to  the 
second,  the  radius  separating  it  from  the  latter. 

12.  But,  when  a  luxation  has  taken  place,  this 
apophysis,  still  remaining  on  a  level  with  the  two 
condyls,  even  although  the  fore-arm  be  half-bent,  is^ 
oftentimes  separated  from  the  internal  one,  and  dri\^en 
towards  the  other:  a  preternatural  protuberance  an- 
nounces this  change  of  position  of  the  olecranon. 
The  coronoid  apophysis,  whose  posterior  surface 
glides  in  the  large  groove  of  tlie  humerus,  coitcs- 
ponds  to  this  groove  now  only  with  its  anterior  sur- 
face: sometimes  the  olecranon  cavity*-  receives  its 
extremity.  The  radius  passes  backward  over  the 
small  head  of  the  humerus.  At  the  fold  of  the  arm, 
a  transverse  protuberance,  more  perceptible  on  the 
internal  side,  announces  the  presence  of  the  displaced 
articular  extremity  of  the  os  humeri.  Over  this  ex- 
tremity are  reflected  the  biceps  and  the  brachialis 
muscles  in  a  state  of  violent  distension.  These  mus- 
cles, greatly  irritated  by  such  distension,  continue  in 
a  state  of  habitual  contraction,  in  consequence  of 
which,  they  keep  the  fore-arm  half-bent.  Nor  can 
the  anconeus  muscle,  which  is  necessarily  relaxed, 
act  so  as  to  prevent  this  semiflection.  Severe  pains 
would  be  the  consequence  of  attempts  to  extend  the 
fore-arm ;  the  limb  is  in  a  state  of  pronation ;  yet  I 
find  among  the  cases  collected  by  Desault,  several 
examples  where  supination  existed;  this  state  is  ex- 
plained by  the  relaxed  condition  of  the  pronator  mus- 

*  That  deep  depression  in  the  os  humeri,  which,  in  a 
natural  state  of  the  parts,  receives  the  upper  end  of  the  ole- 
cranon process.  Trans. 


190 

cles.  At  the  level  of  or  opposite  to  the  coronoid  cavity 
is  a  depression  or  hollow  manifesting  the  absence  of 
the  apophysis  of  that  name. 

13.  Should  chance  give  rise  to  a  luxation  forward, 
an  anterior  projection  of  the  two  bones  of  the  fore- 
arm, and  above  all,  of  the  coronoid  eminence,  a  de- 
pression corresponding  to  the  olecranon  cavity,  the 
extremity  of  the  humerus  carried  backward  and 
downward,  the  rigid  extension  of  the  fore-arm,  a  pro- 
tuberance behind  formed  by  the  fractured  olecranon 
(5),  and  severe  pains,  necessarily  resulting  from  at- 
tempts to  bend  the  limb,  &c.  would  constitute  the 
principal  characteristic  signs  of  the  displacement. 

14.  In  lateral  luxations,  a  protuberance  at  the  in- 
ternal or  external  side  of  the  articulation,  always  shows 
of  what  kind  it  is.  If  the  displacement  be  to  the  in- 
ternal side,  the  olecranon  is  then  situated  behind  the 
small  tuberosity :  the  middle  protuberance  of  the  os 
humeri  bears  on  the  radius,  which  is  sometimes 
placed  even  behind  the  Internal  articular  eminence  of 
that  bone,  which  then  rests  on  the  external  depression 
of  the  great  sigmoid  cavity.  Hence,  as  Petit  judici- 
ously observes,  arises  the  direction  of  the  fore-arm 
outward,  the  above  eminence  presenting  a  manifest 
obliquity  in  that  direction.  In  this  luxation,  the  ulna 
has  been  known  to  lose  entirely  its  connexion  with  the 
humerus,  and  the  radius  to  be  brought  into  contact 
with  the  internal  condyl  of  that  bone.  This  is  what 
some  authors  call  a  complete  luxation.  Others  re- 
serve that  name  for  cases  where,  the  two  articular 
ranges  have  lost  their  correspondence  or  apposition 
entirely. 


191 

15.  In  a  luxation  outwards,  the  olecranon  corres- 
ponds to  the  external  condyl;  the  middle  projection 
of  the  humerus,  to  the  internal  depression  of  the 
great  sigmoid  cavity;  the  small  head  of  this  bone, 
to  the  external  depression;  the  radius  projects  out- 
wards; and  the  humerus  makes  a  protuberance  in- 
wardly. 

16.  After  all,  these  changes  of  situation  vary  re- 
markably, and  it  belongs  to  theory  rather  than  prac- 
tice, to  trace  their  history,  with  precision.  In  gene- 
ral, luxations  outwardly  happen  more  frequently  than 
those  inwardly,  a  circumstance  which  is  fully  ex- 
plained by  the  structure  of  the  joint.  In  both,  the 
lateral  ligaments  are  almost  always  lacerated. 

A  swelling  more  or  less  considerable  accompanies 
all  the  different  kinds  of  luxation,  and  is  sometimes 
carried  so  far  as  to  involve  the  diagnosis  in  great  un- 
certainty, particularly  when  the  displacement  is  not 
very  great.  This  phenomenon  (the  swelling),  seems, 
in  general,  to  correspond,  in  a  direct  ratio,  to  the 
force  with  which  the  articulation  resists.  Indeed  the 
violence,  and  consequently  the  irritation,  are  always 
in  proportion  to  the  resistance  of  the  parts. 

§IV, 

OF   THE   REDUCTION. 

17.  The  means  of  reduction  vary  according 
to  the  different  kuids  of  displacement.  They  ai^e  all, 
however,  founded  on  nearly  the  same  principles,  and 
it  will  be  easy  to  form  proper  ideas  of  them,  when 
we  shall  have  given  an  account  of  the  means  neces- 


192 

sary  to  be  employed  in  luxations  backward,  of  which 
tlie  others  are  only  modifications. 

Here  genius  seems  to  have  been  as  prodigal  of 
resources,  as  nature  has  been  of  obstacles.  Indeed, 
to  accomplish  the  reduction,  we  sometimes  see  the 
surgeon  placing  his  elbow  in  the  fold  of  the  affected 
arm,  interlocking  his  fingers  with  those  of  the  same 
limb,  and,  then,  bending  with  his  whole  force,  both 
his  own  fore-arm,  and  that  of  the  patient,  to  effect  at 
the   same  time  extension,  counter-extension,    and 
reduction  or  conformation:  at  another  time  we  see 
him  fixing  the  fold  of  the  injured  arm  against  some 
resisting  body,  such  as  a  bed-post;  and  while  an  as- 
sistant, then,  pushes  the  displaced  olecranon  against 
tliis  body,  he  himself,  pressing  on  the  shoulder  with 
one  hand,  and  grasping  the  fore-arm  wdth  tlie  other, 
bends  it  forcibly,  in  order,  by  that  means,  to  produce 
a  replacement:  again,  a  body  of  some  size,   being 
placed  in  the  fold  of  the  arm,  serves  as  a  fulcrum,  on 
which  the  fore-arm,  being  suddenly  flexed,   moves 
and  acts  like  a  lever  of  the  first  kind,   of  which  the 
power,  being  applied  at  the  extremity  next  the  hand, 
draws  it  backward  and  upward,  and  by  that  means 
pushes  in  a  contrary  direction  its  luxated  end,  where 
the  resistance  is  made.  On  some  occasions,  the  fore- 
arm of  the  diseased  side,  bent  at  a  right  angle,  is 
placed  on  a  horizontal  table,  and,  while  the  low^er  ex- 
tremity of  the  humerus  is  thus  resting  on  the  table, 
the  surgeon  pushes  it  backward  \\4th  one  hand,  and 
with  the  other,  taking  hold  of  the  extremity  of  the 
fore-arm,  draws  it  in  a  contrary  direction. 


193 

18.  The  ancients  employed  the  three  first  modes. 
Pare  has  had  engravings  of  them  made :  Scultel  has 
also  given  figures  of  them  as  practised  by  Hippo- 
crates. The  Arabians  knew  of  no  other  modes,  nor 
did  their  descendants,  who  were  only  com.pilers  from 
them.  The  practitioners  of  our  own  day  still  conti- 
nue their  use.  But,  in  general,  they  are  chargeable 
with  the  numerous  inconveniences  and  faults  of  pro- 
ducing intense  pain,  of  not  being  completely  under 
the  direction  of  the  surgeon,  of  bringing  the  point  of 
luxation  too  near  to  the  place  on  which  counter-ex- 
tension is  made,  and  of  bruising  and  doing  violence  to 
the  parts :  nor  do  they  disengage,  by  means  of  pre- 
vious extension,  the  luxated  ends  of  the  bones,  to 
facilitate  their  replacement  in  their  natural  situations. 

This  last  charge  is  not  applicable  to  the  last  of 
the  processes  proposed  by  Petit.  But,  here,  the  ex- 
tending forces  are  most  commonly  insufiicient;  the 
surgeon,  having  both  his  hands  engaged,  is  not  able 
to  act  on  the  joint  to  assist  in  the  replacement :  and 
the  counter- extension  made  is  too  near  to  the  point 
of  luxation. 

19.  In  common  cases,  Desault  employed  a  me- 
thod as  simple  and  more  efiicacious,  which  few  wri- 
ters have  recommended,  and  none  have  described 
with  accuracy. 

The  patient  is,  indifferently,  either  seated  or  stand- 
ing. The  fore-arm  being  half-bent,  an  assistant  takes 
hold  of  the  extremity  next  the  hand,  to  make  exten- 
sion ;  another,  to  make  counter-extension,  takes  hold 
of  the  humerus  a  little  below  its  middle,  with  both 

hands,  the  fingers  crossing  before,  and  the  tliumbs 

26 


1^4 

behind.  Tlie  extension  is  made  gradually,  and  when 
it  begins  to  move  the  olecranon,  and  draw  it  from  the 
place  it  accidentally  occupies,  the  surgeon,  to  aid  in 
the  reduction,  grasps  the  lower  end  of  the  humerus 
with  both  hands,  crosses  his  fingers  in  the  fold  of  the 
arm,  applies  his  thumbs  to  the  olecranon,  and  draw- 
ing the  first  backward,  pushes  at  the  same  time  the 
iatter  forwai'd;  thus,  he  favours,  on  the  one  hand  ex- 
tension, and  on  the  other  counter-^extension,  and  in 
that  way  finishes  the  reduction. 

20.  This  method  is  most  commonly  practised 
■with  success,  in  recent  luxations,  where  we  have  of- 
tentimes seen  the  reduction  effected  at  the  Hotel- 
Dieu,  by  the  simple  process  of  pushing,  as  justmicn- 
tioned,  the  olecranon  forward,  the  humerus  being 
held  backward,  without  any  previous  extension,  while 
the  fore-arm  was  merely  supported  by  the  assistants. 

21.  But  the  luxation  being  oftentimes  of  long 
standing,  presents  very  great  difficulties.  What  means 
must  then  be  employed?  It  is  an  established  princi- 
ple, that  the  force  with  which  a  power  acts,  is  in  di- 
rect proportion  to  its  distance  from  the  point  of  resist- 
ance. Augment  this  distance,  and  the  extending 
forces,  being  doubled  and  even  trebled,  will  more 
easily  dislodge  the  luxated  extremity.  But  this  indi- 
cation is  fulfilled,  by  two  long  straps,  formed  each  of 
a  towel  folded  several  times,  one  of  which  is  fixed 
above  the  wrist,  and  the  other  round  the  humerus  a 
little  below  its  middle.  Extension  is  then  made  at 
their  extremities,  and  is  almost  always  sufficient, 
when  aided  by  skilful  efforts  of  the  surgeon  (19),  to 
accomplish  the  reduction.  The  application  of  a  strap 


195 

round  the  humerus  is  never  necessary,  unless  when 
the  resistance  is  very  great;  because,  in  counter- 
extension,  it  is  requisite  only  to  withstand  or  bear 
against  the  efforts  of  extension,  but  not  to  act  in  a 
contrary  direction. 

22.  But  in  cases  of  this  kind,  the  strap,  placed,  as 
Xve  have  directed,  round  the  lower  part  of  tlie  hume- 
rus, has  sometimes  the  disadvantage  of  compressing 
too  much  the  brachialis  and  the  biceps  muscles,  and 
thus  preventing  them  from  acting;  this  inconveni- 
ence is  particularly  felt  in  old  luxations,  where  great 
force  is  employed ;  for,  the  more  active  then  the  con- 
traction of  these  muscles  is,  the  more  it  will  aid  the 
surgeon  in  his  efforts  to  draw  the  bones  into  their  na- 
tural situation,  when  once  disengaged  by  extension, 
from  that  which  they  had  accidentally  occupied.  If, 
in  such  a  case,  we  impede  the  contraction  of  these 
muscles,  how  can  they  fulfil  this  office  ? 

23.  It  was  this  which,  in  certain  cases,  induced 
Desault  to  place  his  counter- extension  under  the  arm- 
pit, by  means  of  a  strap  passing,  as  in  the  luxation  of 
the  humerus,  over  a  ball  previously  fixed  in  this  hol- 
low, and  crossing,  not  on  the  top  of  the  opposite 
shoulder,  but  behind  that  of  the  diseased  side.  By 
this  contrivance  the  humerus  was  drawn  or  rather 
held  back,  by  a  force  acting  perfectly  in  the  line  of 
its  direction.  But  is  not  this  force  situated  too  near 
to  the  centre  of  motion?  The  strap  for  making  exten- 
sion, fastened  at  the  wrist,  answers  very  well,  as  has 
been  already  mentioned  (21). 

24.  Should  the  luxation  be  forward,  the  extension, 
must  be  directed  according  to  the  state  aud  position 


196 

in  which  the  fore-arm  is  found,  which  is  always  ex- 
tended. The  hands  of  assistants  alone  (19),  or 
straps  (21),  may  then  serve  to  mabrthe  extension, 
which  the  surgeon  must  aid,  by  grasping,  in  a  direc- 
tion the  reverse  of  that  in  the  preceding  case,  the 
lower  extremity  of  the  humerus,  that  is,  by  crossing 
his  fingers  behind,  and  placing  liis  thumbs  on  the 
coronoid  apophysis,  to  push  it  downward  and  back- 
ward. 

25.  The  strap  for  counter-extension,  would  in 
such  a  case,  always  afford  the  greatest  advantage,  by 
being  placed  exactly  as  in  luxations  of  the  humerus, 
that  is,  by  running  to,  and  crossing  on,  the  opposite 
shoulder;  the  direction  or  course  of  the  fore-arm, 
which  is  necessarily  in  a  state  of  extension,  sufficient- 
ly explains  this ;  finally,  the  reduction  of  the  luxation 
must  be  succeeded  by  the  reduction  of  the  olecranon 
(5),  and  by  the  application  of  a  proper  apparatus  to 
retain  the  whole. 

26.  The  reduction  of  lateral  luxations,  differs  but 
little  from  that  of  luxations  backwards.  The  dis- 
placed extremities  must  be  first  dislodged  by  previ- 
ous extension  (19).  The  surgeon,  then,  taking  hold 
of  the  lower  part  of  the  arm,  places  his  fingers  before, 
and  with  his  thumbs,  crossed  on  the  olecranon, 
pushes  that  apophysis  forward  and  inward,  if  the  dis- 
placement be  outwardly,  but  forward  and  outward 
if  it  be  inwardly.  Does  the  case  prove  very  difficult, 
recourse  must  be  had  to  the  other  means  (21  and  23). 
The  hands  of  the  surgeon  must  still,  according  to 
the  direction  of  the  displacement,  assist  the  extension 
made  by  the  straps. 


107 


OF   THE   MEANS  OF   MAINTAINING   THE 
REDUCTION. 

27.  Luxations  of  the  fore-arm  have,  oftentimes, 
a  great  disposition  to  occur  anew,  after  having  been 
reduced,  whether  they  be  recent,  or  of  long  standing. 
Extension  readily  dislodges  the  olecranon  and  the 
radius,  and  replaces  them  perfectly  in  their  natural 
situation;  but  if  any  thing  interrupt  them,  the  dis- 
placement is  sometimes  immediately  renewed :  sup- 
pose the  parts  even  remaining  in  contact,  the  slight- 
est motion  may  derange  this  contact,  and  give  rise  to 
a  necessity  for  a  new  reduction,  more  difficult,  often- 
times, than  the  first.  Hence  it  is  alwaj^s  prudent  to 
employ  a  retentive  apparatus  for  some  time. 

28 i  But,  on  what  principle  and  for  what  purpose 
ought  it  to  be  applied?  The  motions  communicated 
to  the  fore-arm  by  external  bodies,  but,  more  parti- 
cularly, the  action  of  the  muscles  inserted  in  the  bones 
that  have  been  reduced,  are  here  the  causes  of  their 
displacement.  Hence,  1st,  to  render  the  limb  im- 
moveable; 2dly,  to  push  the  articular  ends  of  the 
bones  in  a  direction  opposite  to  that  in  which  they 
are  drawn  by  the  muscles,  and  have  a  tendency  to  be 
displaced :  such  is  the  twofold  indication  of  the  ban- 
dage ;  an  indication  not  fulfilled  by  the  kind  of  ban- 
dage and  the  sling  which  Petit  proposed,  and  which 
leave  the  arm  free  to  move,  and  the  muscles  free 
to  act. 


198 

29.  Desault  employed  the  following  apparatus : 
1st,  The  ai'm  and  fore-arm  are  first  covered  by  oblique 
turns  of  a  roller,  intended  both  to  protect  them  from 
the  impression  of  splints,  and  to  dirninish  the  power, 
and  action  of  the  muscles,  by  the  pressure  made  on 
them :  2dly,  Behind  the  olecranon  is  to  be  placed  a 
thick  compress,  designed  to  retain  it  dowiiwai'ds,  and 
which  must  be  secured  by  a  strong  splint,  situated 
behind,  and  curved  at  the  elbow,  to  accommodate  it 
to  the  flexion  of  the  fore-arm :  3dly,  On  the  sides  are 
placed  two  other  splints,  chiefly  necessaiy  in  lateral 
luxations :  4thly,  The  whole  is  to  be  secured  by  the 
remaining  part  of  the  roller,  by  which  the  arm  and 
fore-arm  are  already  covered. 

In  this  bandage,  the  immobility  of  the  arm  is 
secured  by  the  splints,  while  the  olecranon  is  pushed 
by  the  compress,  in  a  direction  the  reverse  of  that  of 
its  displacement.  But  these  circumstances  constitute 
the  double  indication  tliat  was  to  be  fulfilled  (28). 

30.  The  period  at  which  these  means  may  be  dis- 
pensed with,  is  undetermined.  It  belongs  to  the 
surgeon  to  examine  and  ascertain,  when  the  natural 
connexions  of  the  joint  ai-e  sufl[iciently  confirmed. 
Then  motions,  at  first  gentle,  are  to  be  impressed  on 
the  limb ;  being  afterwards  gradually  increased,  they 
remove  by  degrees  that  stiflhess,  which  usually  fol- 
lows a  dislocation,  particularly  an  old  one.  But  if  it 
has  existed  too  long,  to  give  the  limb  motion,  is  then 
the  only  resource :  the  new  attachments  or  adhesions, 
contracted  by  the  articulating  surfaces  in  their  dis- 
placed state,  render  reduction  impracticable.  We 
must  then  confine  ourselves  merely  to  increasing  the 


199 

extent  of  the  motions,  which  the  displaced  fore-arm 
is  yet  capable  of  performing. 

31.  There  is,  in  general,  all  other  things  being 
favourable,  a  hope  of  accomplishing  the  reduction, 
till  the  end  of  the  second  month  after  the  accident. 
Desault  succeeded  in  it,  at  even  a  later  period.  What 
trouble  or  hardship  is  it,  at  last,  to  try  extension? 
Should  no  other  end  be  gained,  but  merely  to  bring 
the  bones  nearer  to  their  natural  cavities  or  situations, 
even  without  actually  replacing  them,  this  will  aid 
their  movements,  the  extent  of  which  is  inversely 
proportioned  to  their  distance  from  these  oavities. 


MEMOIR  X. 

ON^THE   LUXATIONS  OF    THE   RADIUS   OVER    THE 

ULNA. 

1st,  Most  authors  who  have  written  on  the  lux- 
ntions  of  the  fore-arm,  have  omitted  considering  se- 
parately those  confined  to  the  radius  alone.  Some 
detached  observations  may  be  found  here  and  there, 
on  the  luxations  of  the  upper  extremity  of  this  bone, 
which  Duvemey  alone  has  treated  at  some  length. 
Those  of  its  lower  extremity,  though  more  frequent, 
and  more  easily  produced,  appear  to  have  almost 
entirely  escaped  the  attention  of  the  French  practi- 
tioners, who  have  transmitted  nothing  to  us  on  that 
point,  owing,  no  doubt,  to  their  having  had  no 
knowledge  of  it  from  experience.    But  since,  at  the 


200 

present  day,  a  sufficient  number  of  facts  are  collected 
on  the  subject,  some  account  of  these  displacements 
cannot  be  a  matter  of  indifference  to  the  art,  and  it 
may  be  traced  with  as  much  precision  as  the  accounts 
of  other  similar  accidents. 


I. 


OF  THE  DIFFERENCES  IN  POINT  OF  STRUCTURE 
BETWEEN  THE  TWO  ARTICULATIONS  OF  THE 
RADIUS   WITH    THE    ULNA.    ' 

2.  The  radius,  the  moveable  agent  in  pronation 
and  supination,  rolls  on  the  ulna  its  fixed  basis  or  abut- 
ment, by  means  of  two  small  articulating  surfaces,  the 
one  at  its  upper  end,  slightly  convex,  broad  within, 
and  narrow  without,  coiTCsponding  to  the  small  sig- 
moid cavity,  in  which  it  is  lodged ;  and  the  other 
at  its  lower  end,  concave,  semicircular,  and  fitted  to 
the  convex  edge  of  the  ulna,  which  it  receives.  Hence 
two  kinds  of  articulation  different  fi-om  each  other, 
v/ith  respect  to  their  motions,  the  connexion  of  their 
surfaces,  and  the  ligaments  which  strengthen  them. 
Let  us  specify  these  differences ;  they  will  serve  to 
shed  light  on  those  that  exist  between  the  displace- 
ments of  the  two  extremities  of  the  radius. 

3.  At  its  upper  end,  the  radius,  in  performing 
pronation  and  supination,  moves  only  on  its  o\Yn  axis ; 
at  its  lower  end,  it  roils  round  the  axis  of  the  ulna: 
therefore,  being  farther  removed  from  their  centre, 
its  motions  must  have  both  a  greater  range  and  greater 
force,  in  the  latter  case  than  in  the  former.  The 
head  of  the  radius,  turning  on  itself  within  the  annu- 


201 

lar  ligament,  cannot  distend  it  in  any  direction  or 
part.  The  cellular  membrane  attached  to  this  liga- 
ment is  alone  slightly  stretched,  but  being  loose  and 
elastic,  it  yields  without  resistance.  At  its  lower 
end,  on  the  contrary,  the  radius,  turning  from  with- 
out inwards  during  pronation,  keeps  the  capsule 
posteriorly  in  a  state  of  tension,  and  draws  it  against 
the  immoveable  head  of  the  ulna,  which  tends  to  pass 
through  it,  if  the  motion  be  forcible.  The  same 
phenomenon  occurs  in  a  contrary  direction,  during 
supination;  the  radius  is  directed  backward,  and  the 
ulna  inward.  Being  in  this  case  distended  before, 
and  relaxed  behind,  the  capsule  is  disposed  to  lace- 
ration anteriorly. 

4.  In  addition  to  this  disposition,  the  ligaments 
of  the  two  articulations  are  disproportioned  in  their 
strength.  Thin  and  weak  at  the  lower  articulation, 
thick  and  firm  at  the  upper  one,  they  are  in  this  re- 
spect strikingly  diflPerent.  The  head  of  the  radius, 
resting  against  the  small  but  firmly  fixed  head  of  the 
humerus,  finds  there,  in  most  of  its  movements,  an 
obstacle  to  displacement.  On  the  contrary,  its  lower 
end,  drawing  along  with  it  in  its  movements,  the 
bones  of  the  carpus  which  are  connected  with  it,  de- 
rives from  them  no  solid  support. 


27 


202 


II. 


DIFFERENCES  IN  THE  LUXATIONS  OF  THE  RA- 
DIUS; DIFFICULTIES  OF  THAT  AT  ITS  UPPER 
END. 

5.  It  follows  from  what  has  been  said  (3  and  4), 
1st,  that  the  lower  articulation  of  the  radius  is  not  only 
exposed  to  the  action  of  more  causes  of  displacement, 
but  possesses  fewer  means  of  resisting  those  causes, 
and  that,  from  the  threefold  consideration  of  its 
motions,  the  ligaments  which  connect  its  articulating 
surfaces,  and  their  relation  to  each  other,  it  must  be 
frequently  subject  to  luxations :  2dly,  that  for  reasons 
the  very  reverse  of  these,  its  upper  articulation  must 
be  very  seldom  subject  to  luxation. 

6.  Indeed,  what  cause  is  there  to  produce  luxa- 
tion in  this  latter  joint.  Is  it  from  a  forcible  exertion 
of  pronation  or  supination  that  this  accident  can  oc- 
cur? Surely  not:  for,  on  the  one  hand,  as  the  lower 
articulation  offers  less  resistance  than  the  upper  one, 
it  is  evident  that,  in  either  state  of  motion,  it  being 
the  weakest,  will  be  displaced  first,  and  the  motion 
being  thus  checked,  can  no  longer  operate  to  the  dis- 
placement of  the  otlier.  On  the  other  hand,  however 
forcible  the  motion  may  be,  there  will  be  in  the  upper 
articulation,  nothing  but  a  rotation  of  the  bone  on  its 
own  axis  (3).  How,  then,  without  being  carried  for- 
ward, backward,  &c.  can  the  head  be  displaced? 
Indeed,  it  would  be  necessary  that  all  the  fastenings 
or  bonds  of  attachment  muscular  and  ligamentous, 
should  be  first  broken.  But  these  are  too  strong,  and 


203 

the  motion  is  too  weak.  Can  the  displacement  be 
produced  by  a  blow  impressed  on  the  radius  from 
below  upwards?  By  no  means:  because  the  head 
of  the  humerus  making,  in  this  case,  a  solid  resistance 
will  not  permit  it  to  escape  from  the  capsule  (4). 
Can  it  arise  from  a  violent  extension  or  flexion  of 
the  fore-arm?  No.  This  effort  being  altogether  con-r 
fined  to  the  ulna,  affects  the  radius  in  but  a  very  faint 
degree. 

7.  It  appears  from  hence,  that  the  accidental  lux- 
ation of  the  upper  end  of  the  radius,  suddenly  pro- 
duced by  external  causes,  must,  if  it  ever  occur,  be 
extremely  rare.  But  it  is  not  so  with  respect  to  luxa- 
tions which  take  place  slowly  in  tliis  joint,  particularly 
in  children,  where,  in  consequence  of  repeated  efforts, 
the  ligaments  become  relaxed.  But  this  kind  of  dis- 
placement, being  almost  always  complicated  with  a 
swelling  of  the  joint,  and  sometimes  not  to  be  redu- 
ced by  the  expedients  of  art,  cannot  be  comprised  in 
my  present  plan. 

9.  But  experience  would  seem  to  have  at  times 
exposed  the  fallacy  of  these  considerations  and  rea- 
sonings, founded  merely  on  the  structure  of  the  parts. 
Duvemey  relates  some  instances  of  luxations  of  the 
head  of  the  radius,  produced  suddenly  by  external 
causes.  Two  other  practitioners  ai'e  also  of  opinion 
that  they  have  witnessed  similar  displacements.  But 
did  they  examine  the  subject  with  all  that  attention 
which  it  required?  A  similar  case  was  reported  to  the 
Academy  of  Surgery,  by  one  of  its  associates;  but 
doubts  were  entertained  with  regard  to  its  reality  i 
and,  ultimately,  there  were  so  few  facts  in  its  favour. 


204 

and  such  strong  presumptions  against  it,  that  Desault 
was  induced  to  deny  the  luxation  altogether,  till  its 
reality  should,  by  new  proofs,  be  more  certainly 
established. 

After  all,  if  it  should  occur,  the  same  signs  which 
announce  the  luxation,  when  the  ligaments,  in  conse- 
quence of  being  gradually  relaxed  or  in  some  way 
distended,  permit  the  head  of  the  radius  to  be  insen- 
sibly displaced,  would  then  appear  as  the  sudden  ef- 
fect of  external  violence. 


LUXATION  OF  THE  LOWER  EXTRE- 
MITY OF  THE  RADIUS. 

UIL 

OF   THE   KINDS   OP   DISPLACEMENT. 

9.  The  causes  which  produce  the  displacement 
of  the  lower  end  of  the  radius,  are  the  same  with  those 
that  give  rise  to  other  similar  affections.  1st,  The 
convulsive  action  of  the  pronator  and  supinator  mus- 
cles, is  doubtless  a  rare  cause  of  the  accident,  since 
Desault  never  met  with  an  instance  of  it.  2dly,  The 
action  of  external  bodies,  which,  by  forcibly  and  sud- 
denly producing  the  motions  of  pronation,  rupture 
the  posterior  portion  of  the  capsule,  or,  by  those  of 
supination,  lacerate  its  anterior  portion. 

10.  Hence  two  kinds  of  displacement,  the  one 
forward,  the  other  back\A^ard.  The  first  is  somewhat 
frequent;  the  second  is  much  less  so.  The  latter  was 
never  seen  by  Desault  but  once,  and  that  was  in  the 


205 

corpse  of  a  man  who  had  had  both  his  arms  luxated, 
but  respecting  the  circumstances  of  which  he  could 
receive  no  information.  The  other  kind  occurred  fre- 
quently in  his  practice,  of  which  five  examples  have 
been  already  published.  The  difference  no  doubt 
arises  from  this  circumstance,  that  the  greater  part 
of  our  powerful  motions  are  performed  only  in  the 
direction  of  pronation.  This  appears  to  be  proven  by 
the  following  circumstances. 

11.  If,  in  several  dead  bodies,  we  lay  bare  the 
bones  of  the  fore-arm,  still  united  by  their  ligaments, 
and  push  the  extremity  of  the  radius  forcibly  back- 
wards, that  is,  in  the  direction  of  supination,  a  lacera- 
tion will  as  readily  occur  in  the  anterior  part  of  the 
capsule,  as  it  will  in  its  posterior  part,  when,  by  for- 
cibly pushing  the  same  extremity  forward,  the  motion 
of  pronation  is  performed.  Hence  the  difference  does 
not  arise  from  the  structure,  but  from  the  direction 
of  the  motions  impressed  on  the  limb. 

•OF   THE   SIGNS. 

12.  The  signs  which  characterize  a  luxation  of 
the  radius  forward,  are,  1st,  The  constant  pronation 
of  the  limb :  2dly,  An  inability  in  it  to  assume  the 
state  of  supination,  and  even  severe  pains  arising 
from  attempting  it :  3dly,  A  protuberance  larger  than 
common,  formed  behind,  by  the  small  head  of  the 
ulna  passing  through  the  capsule :  4thly,  The  end  of 
the  radius  being  situated  more  anteriorly  than  natural : 
5thly,  The  constant  adduction,  and  almost  constant 


206 

extension  of  the  wrist:  6th]y,  The  semiflexion  of 
the  fore-arm,  and  very  often  of  the  fingers :  this  po- 
sition is  generally  assumed  by  the  fore-arm,  in  affec- 
tions of  the  bones  that  form  it,  and,  in  the  present 
case,  cannot  be  changed  without  considerable  pain : 
7thly,  A  swelling  more  or  less  extensive,  which  some- 
times appears  around  the  articulation,  at  the  moment 
of  the  accident,  and  which  never  fails  to  occur  after- 
wards, unless  the  reduction  be  immediately  effected. 
This  occurrence  may  conceal  the  state  of  the  articu- 
lation, and  make  the  accident  be  considered,  at  first 
sight,  as  a  sprain,  as  Desault  v/itnessed  in  certain 
cases,  where  the  disease  had  been  mistaken  by  the 
surgeons  who  were  first  called  to  the  persons  injured. 
It  is  easy  to  conceive  of  the  sad  consequences  of  this 
mistake,  which,  by  preventing  any  effort  at  reduc- 
tion, gives  the  articular  surfaces  time  to  form  adhe- 
sions, and  thus  oftentimes  renders  the  mischief  irre- 
parable. 

13.  If  to  these  signs  be  added,  the  severe  pains 
experienced  by  the  patient,  the  circumstances  of  the 
fall,  in  which  the  fore-arm  is  violently  di^awn  into  a 
state  of  pronation,  we  will  have  a  view  of  every  thing 
that  can  here  aid  the  practitioner  in  his  diagnosis. 

14.  Most  of  the  foregoing  signs,  taken  in  the  op- 
posite sense,  would  chaiTtcterize  a  luxation  of  the  ra- 
dius backvv^ard,  should  it  occur :  such,  for  example, 
as  a  forced  supination  of  the  limb,  an  inability  as  to 
pronation,  the  pains  that  would  result  from  this  move- 
ment if  performed  by  force,  the  tumour  formed  ante- 
riorly by  the  extremity  of  the  ulna,  the  posterior 
situation  of  the  large  head  of  the  radius,  and  the  ab- 
duction of  the  v/rist. 


207 

15.  The  dead  body,  in  which  Desault  observed 
this  kind  of  displacement  (9),  being  dissected  with 
care,  exhibited  in  the  articular  paits,  the  following 
diseased  state.  The  tendons  of  the  flexor  muscles, 
pushed  outwards,  adhered  to  one  another  and  to  the 
skin ;  a  substance  of  a  cellular  texture  filled  up  the 
sigmoid  cavity  of  the  radius,  and  occupied  the  place 
of  the  cartilage  which  naturally  invests  it :  the  inter- 
articular  ligament,  which  passes  between  the  ulna 
and  the  os  pyramidalis,  scaicely  touched  the  head  of 
the  ulna,  having  followed  the  radius  backwards;  and 
the  head  of  the  ulna,  situated  before  the  sigmoid 
cavity  of  the  radius,  rested  on  one  of  the  ossa  sesa- 
moidea,  to  which  it  was  attached  by  a  capsular  liga- 
ment. 

'       ^  V. 

OF   THE    REDUCTION 

16.  Extension  so  important  in  the  reduction  of 
other  luxations,  renders  scarcely  any  service  in  this: 
impulsion  alone  ansv/ers  the  purpose.  If  the  dis- 
placement be  forward,  it  is  reduced  in  the  foliov/ing 
manner :  The  patient  sits  or  stands  indifferently ;  the 
latter  position,  however,  has  sometimes  this  advan- 
tage over  the  former,  that  by  placing  the  part  to  be 
operated  on  more  on  a  level  with  the  hands  of  the 
surgeon,  it  gives  him  both  more  readiness  and  more 
force  in  his  motions:  one  assistant  supporting  tlie 
elbow,  separates  the  arm  a  little  from  the  body ;  while 
another  taking  hold  of  the  hand  and  fingers,  gives 
them  also  an  equable  support. 


208 

17.  The  surgeon  grasps  the  extremity  of  the  fore- 
arm, with  both  hands,  one  placed  on  its  internal,  and 
the  other  on  its  external  side,  so  that  his  two  thumbs 
may  meet  before,  between  the  ulna  and  the  radius, 
and  the  fingers  behind.  He  then  exerts  himself  to 
separate  the  two  bones  from  each  other,  by  pushing 
the  radius  backward  and  outward,  and  retaining  the 
ulna  in  its  place ;  in  the  mean  time  the  assistant  who 
supports  the  hand,  endeavours  to  move  it  in  the 
direction  of  supination,  and  consequently  to  draw  the 
radius,  with  which  it  is  connected,  into  the  same 
state.  Being  thus  pushed  in  a  direction  opposite 
to  that  of  its  displacement,  by  two  forces,  the  one 
exerted  directly  on  it,  and  the  other  acting  indirectly, 
the  radius  is  forced  outwards,  and  the  ulna,  return- 
ing through  the  opening  in  the  capsule,  is  replaced 
in  the  sigmoid  cavity. 

18.  Should  a  luxation  of  the  radius  backwards 
ever  occur,  the  same  process  executed  in  an  inverse 
direction,  would  serve  the  purposes  of  reduction. 
The  surgeon  with  his  fingers  would  have  to  press 
the  extremity  of  the  radius  forward  and  inward,  while 
a  forcible  pronatory  movement  impressed  by  the  as- 
sistant on  the  hand  intrusted  to  him,  would  favour 
the  effort  and  finish  the  reduction. 

.19.  The  disappearance  of  the  signs  (12....  14)  of 
the  luxation  bespeak  its  reduction.  In  general  the 
pain  is  entirely  removed;  sometimes  a  perceptible 
sound,  or  report,  caused  by  the  passage  of  the  bone 
through  the  opening  in  the  capsule,  announces  the 
replacement. 


209 

20.  When  the  luxation  is  of  long  standing,  it  is 
always  attended  with  more  or  less  difficulty,  occa- 
sioned by  the  adhesions  of  the  surrounding  soft  parts 
to  the  articulating  surfaces,  by  the  thickening  of  the 
capsule,  which  diminishes  the  size  of  its  opening, 
by  the  rigidity  contracted  by  the  whole  part,  &:c.  It 
is,  in  such  cases,  useful  to  employ  emollient  applica- 
tions for  some  time  previously  to  attempting  the  re- 
duction, in  order  to  produce  such  a  relaxation,  and 
diminution  of  the  congestion,  as  may  fevour  the 
efforts  of  the  surgeon. 

21.  The  first  patient  whom  Desault  visited  at  the 
Hotel- Dieu  in  quality  of  surgeon  in  chief,  had  a 
luxation  forward,  of  more  than  two  months  standing, 
in  which  the  use  of  these  means  facilitated  the  re- 
duction: but  they  are  sometimes  insufficient,  and 
then  the  radius  remains  immoveable,  and  the  fore- 
aiTTi  performs  its  motions  but  partially. 

22.  It  would  seem  as  if  nature,  always  industrious 
to  provide,  amid  the  disorders  of  our  organs,  some 
resources  for  the  exercise  of  their  functions,  has  been 
desirous  of  preventing  here,  the  inconvenience  at- 
tendant on  a  failure  of  reduction,  by  rendering  lux- 
ations backward  much  more  difficult  than  those  for- 
ward. Indeed  if  the  fore-arm  be  kept  constantly  in 
a  state  of  supination,  it  will  be  much  less  useful, 
than  if  it  were  always  in  a  state  of  pronation,  the 
situation  in  which  most  of  the  motions  necessary  to 
our  existence  are  performed. 

28 


210 

§VI. 

OF  THE   SUBSEqUENT  TREATMENT. 

23.  When  the  reduction  is  finished,  the  articulat- 
ing surfaces  have  sometimes  a  great  tendency  to  be 
displaced,  by  the  different  movements  of  the  fore-arm, 
a  tendency  of  which  we  may  easily  form  an  idea,  if 
we  observe,  that  in  a  state  of  pronation,  the  head  of 
the  ulna  presses  against  the  back  part  of  tlie  strained 
capsule,  and  consequently  against  its  opening,  when 
the  luxation  has  been  forward:  a  contrary  state  of 
things  occurs  in  a  luxation  backwai^d.  Whence  it  is 
always  prudent  to  avoid,  for  some  time,  the  motions 
of  pronation  and  supination,  according  to  the  direction 
of  the  displacement. 

24.  Should  the  tendency  to  displacement  be  very 
great,  it  will  be  necessary  to  adopt  the  simple  me- 
thod pointed  out  in  a  case  already  published  by  De- 
sault. 

Case  I.  The  case  was  a  luxation  fonvard,  which 
was  easily  reduced.  But  the  easier  the  reduction,  the 
miore  difficult  wsls  it  to  retain  the  replaced  parts.  This 
was  at  length  accomplished,  by  fixing  the  fore-ai'm  in 
a  state  of  supination,  and  applying  one  thick  compress 
behind  the  uhia,  wliile  the  radius  was  pushed  back- 
ward by  another  compress,  placed  on  its  anterior  part, 
both  secured  by  a  common  roller.  This  apparatus 
was  continued  for  the  space  of  a  month,  after  wliich 
the  reduced  bones  remained  in  their  natural  situation. 
The  patient  began,  at  first,  to  perform  gentle  motions 
of  the  wrist,  avoiding  those  of  pronation,  on  wliich 


211 

he  afterwards  ventured  by  degrees,  and  with  great 
caution. 

25.  These  gentle  motions  frequently  repeated, 
when  a  displacement  is  no  longer  to  be  apprehended, 
remove  that  unavoidable  rigidity  which,  for  some 
time,  occupies  the  parts  ai'ound  the  joint.  It  is  ad- 
visable, for  some  time,  to  apply  on  the  hand  and 
extremity  of  the  fore-arm,  compresses  wet  with  some 
discntient  liquor,  to  prevent  the  swelling  resulting 
perhaps  from  the  inactivity  and  sprain  of  the  parts. 
This  was  the  practice  of  Desault. 

I  will  close  this  memoir  by  two  cases,  extracted 
from  the  Journal  of  Surgery,  in  order  to  confirm,  by 
experience,  what  has  been  already  settled  in  theory. 

Case  I.  Desault  was  called  to  visit  a  child  five 
years  old,  supposed  to  be  labouring  under  a  fi^acture 
of  the  arm.  He  learnt  from  the  pai^ents  of  the  child, 
that,  as  it  was  lying  in  a  very  low  bed,  a  young  man 
who  was  playing  with  it,  had  taken  hold  of  its  fore- 
ann,  and  di'awn  it  towards  him,  twisting  it  forcibly 
at  the  same  time  in  the  direction  of  pronation ;  that  the 
eifort  had  been  accompanied  by  a  report,  and  the 
child  had  immediately  experienced  an  acute  pain 
throughout  the  whole  limb,  but  more  pailicularly 
along  the  posterior  part  of  the  fore-arm. 

When  Desault  saw  the  patient,  no  swelling  had  as 
yet  supervened ;  the  arm  was  rem^oved  fi-om  the  body, 
and  canied  a  little  forward,  while  the  fore-arm,  half- 
bent,  was  kept  in  a  state  between  pronation  and  supi- 
nation. There  existed,  at  its  lower  and  back  pait,  a 
preternatural  tumour,  formed  by  the  head  of  the  ulna 
carried  behind  the  sJ2:moid  cavitv  of  the  radius.   The 


212 

hand  was  a  little  extended,  and  in  a  state  of  adduction.' 
The  patient  carefully  preserved  that  position,  and,  as 
soon  as  it  was  changed,  or  the  part  affected  touched, 
manifested  signs  of  the  most  acute  pain. 

From  these  appearances,  Desault  discovered  im- 
mediately a  luxation  of  the  radius  for^vard,  which  was 
reduced  in  the  manner  already  mentioned  ( 16  and  17). 
By  this  process,  the  bones,  being  a  little  separated 
from  each  other,  were  replaced  with  facilit)^  The 
suffering  of  the  patient  w^as  immediately  at  an  end; 
the  limb  resumed  its  natural  state,  and  performed  its 
functions  as  freely  as  before ;  lest  some  congestion 
might  be  the  consequence,  the  injured  parts  were 
covered  by  compresses  wet  with  camphorated  spirits ; 
these  were  secured  by  a  bandage  moderately  tight, 
and  no  accident  whatever  supervened. 

Case  II.  On  the  29th  of  January,  1789,  Made- 
leine Fuser,  a  washer-woman,  thirty-four  years  of 
age,  had  the  lower  extremity  of  the  radius  luxated 
forward. 

Just  as  she  had  finished  wringing  a  sheet,  another 
washer- woman,  who  was  assisting  her  to  wring  it, 
giving  it  a  forcible  jerk,  did  violence  to  her  left  arm, 
which  w^as  at  the  time  in  a  state  of  strong  pronation. 

The  woman  experienced  immediately  a  severe 
pain,  accompanied  by  a  sensation  as  if  something  had 
been  torn.  The  sheet  dropt  from  her  hand,  and  she 
fell  on  the  ground.  Believing  that  she  had  receiv- 
ed only  a  sprain,  she  neglected  to  apply  for  aid,  and 
did  not  enter  the  Hotel-Dieu  till  the  sixth  day  after 
the  accident. 


213 

There  was  then  a  Httle  swelling  at  the  lower  part 
of  the  fore-arm  and  at  the  wrist :  the  latter  was  ex- 
tended and  in  a  state  of  adduction;  the  fingers  were 
bent.  This  woman  suffered  but  little,  when  her  hand 
was  supported  and  kept  still ;  but  the  pains  became 
severe,  when  she  attempted  to  move  it.  It  was  plain- 
ly perceived  that  the  radius  was  placed  before  the 
ulna,  and  that  the  bones  overlapped  each  other. 

Process  of  reduction  the  same  as  in  the  preceding 
case.  It  was  accompanied  by  a  kind  of  report,  and 
its  completion  was  clearly  announced  by  the  restora- 
tion of  the  natural  shape  of  the  limb,  and  by  the  free- 
dom of  its  motions.  Cojnpresses  wet  with  vegeto- 
mineral  water  were  applied  to  the  \\Tist. 

This  patient  remamed  fifteen  days  in  the  hospital, 
at  the  end  of  which,  she  performed  with  ease  the  mo- 
tions of  the  \mst  and  hand. 


214 
MEMOIR  XI. 

ON  THE  FRACTURES  OF  THE  THIGH* 

1.  The  OS  femoris,  being  in  man,  a  moveable 
support  for  the  weight  of  the  whole  body,  appears  to 
be  better  secured  than  the  other  bones,  from  accidents 
tliat  might  affect  its  continuity.  The  numerous  masses 
of  muscle  that  immediately  surround  it;  the  thick 
and  compact  layers  or  fascics  that  form  its  more  exte- 
rior covering ;  and  an  articulation  loose,  and  ready  to 
yield,  in  every  direction,  to  the  motions  impressed 
on  it,  all  seem,  on  the  one  hand,  calculated  for  its 
preservation. 

2.  But,  on  the  other  hand,  being  visibly  curved 
in  its  middle,  bent  at  its  upper  end  almost  at  a  right 
angle,  longer  in  proportion  in  man  than  in  quadru- 
peds, placed,  in  most  falls,  between  the  ground  which 
resists,  and  the  weight  of  the  body  which  presses  on 
it;  it  would  seem,  from  these  latter  circumstances, 
to  be  less  calculated  to  resist  external  force.  And,  if 
to  these  considerations  be  added  those  of  the  causes 
which  have  an  immediate  action  on  it,  it  will  be  easy 
to  perceive,  that,  in  a  comparative  scale  of  the  bones 
most  exposed  to  fractures,  it  holds,  next  to  the  bones 
of  the  leg,  one  of  the  highest  grades.  The  propor- 
tion which  its  fractures  bear  to  those  of  the  leg,  is, 
according  to  the  observations  of  Desault,  as  one  to 
three;  but  to  that  of  most  other  bones  it  is  equal  if 
not  superior. 


215 

S.  The  OS  femoris,  being  in  its  body  irregularly 
cylindrical  and  curved  behind,  becomes  larger  to- 
wards its  lower  end,  where  it  terminates  in  two  artic- 
ulating masses,  which  rest  immediately  on  two  cor* 
responding  surfaces  of  the  os  tibiae;  changing  its 
direction  above,  it  inclines  towards  the  acetabulum, 
and  inserts  into  that  cavity  a  round  head,  supported 
by  a  neck  which  is  entirely  enclosed  in  the  capsule 
of  the  joint. 

4.  From  this  different  conformation  of  its  different 
parts,  arises  such  a  variety  in  the  fractures  which  oc-  ^ 
cur  in  it,  that  they  cannot  be  treated  of  under  the  ' 
same  head.  Hence  the  division  into  fractures  of  the 
body  and  of  the  extremities,  which  is  borrowed  from 
anatomists,  and  will  be  followed  in  the  present  me- 
moir, where  we  will  consider  in  order,  j 

1st,  The  fractures  of  its  body, 
:2dly,  Those  of  its  upper  extremity, 
3dly,  Those  of  its  lower  extremity. 

FRACTURES  OF  THE  BODY  OF  THE  OS 
FEMORIS.  I 

ui. 

OF   THE   VARIETIES   AND   CAUSES. 

5.  The  OS  femoris  may  be  fractured  indifferently 
at  any  point  between  its  condyls  and  its  neck.  But 
the  part  where  tliis  accident  most  frequently  occurs, 
is  about  the  centre  of  the  curve  of  the  bone,  where 
most  of  the  motions  and  shocks  impressed  on  it  by 
e:5ternal  violence  expend  their  force. 


216 

6.  Whatever  may  be  the  seat  of  the  fracture,  its 
direction  is  sometimes  transverse,  but  most  frequent- 
ly oblique,  a  variety  which  does  not  affect  the  real 
nature  of  the  disease,  but  which  possesses,  as  to  its 
consequences,  a  very  impoitant  influence.  As  in  other 
affections  of  the  kind,  so  here,  the  bone  is  sometimes 
affected  alone,  and,  at  other  times,  to  a  fracture  sim- 
ple or  complicated  by  means  of  spUnters,  is  added 
an  injury  done  to  the  surrounding  soft  parts.  Hence 
result  compound  fractures,  differently  varied,  accor- 
ding to  the  nature  of  the  parts  affected,  and  to  the  ex- 
tent and  other  circumstances  of  these  affections.  But, 
as  Petit  observes,  this  bone  is  less  frequently  shatter- 
ed or  crushed  into  several  pieces,  than  those  that  are 
more  superficially  situated, 

7.  Extraneous  causes  are  kno^'VTi  to  render  falls 
more  frequent  in  man  than  in  other  animals,  and  to 
multiply  in  him  the  fractures  of  the  lower  extremities, 
by  m.ultiplying  the  action  of  external  bodies  on  these 
extremities.  This  action  may  be  exerted  on  the  os 
femoris  in  two  modes.  Sometim.es  only  passive,  it 
merely  offers  a  resistance  to  the  power  which  puts  the 
bone  in  motion;  thus,  in  a  fall,  the  os  femoris,  being 
pressed  between  the  ground  which  resists,  and  the 
weight  of  the  body  that  bears  on  it,  bends  beyond 
the  extent  of  its  flexibility  or  pliancy,  and  finally  gives 
wav.  At  other  times  the  influence  of  external  bodies 
is  actively  and  directly  exerted  in  this  accident :  thus 
a  stone,  or  a  piece  of  timber,  falling  on  the  thigh, 
fi'actures  the  bone,  in  consequence  of  communicat- 
ing to  it  a  degree  of  motion  greater  than  its  power 
of  resistance. 


217 

5.  In  common,  the  first  mode  of  division  is  by  a 
tru€  counter- stroke,  similar  to  that  which  fractm'es 
the  clavicle,  the  ribs,  &c.  In  the  second  mode,  the 
fracture  is  always  direct.  The  middle  part  of  the 
bone  is  generally  broken  in  a  counter- stroke:  where- 
ever  the  direct  stroke  is  received,  that  is  the  place 
of  the  fracture  which  it  produces ;  the  division,  most 
frequently  oblique  in  the  first  case,  is  sometimes 
perpendicular  or  transverse  in  the  second.  From  a 
counter- stroke  result  most  commonly  simple  frac- 
tures, while  compound  ones  are  usually  owing  to  a 
direct  stroke. 

§  III. 

OF    THE    SIGNS   AND    THE   DISPLACEMENT. 

9.  In  whatever  manner  a  fracture  of  the  os  femo- 
ris  may  have  occurred  (7),  its  existence  is  character- 
ized by  the  following  signs :  severe  local  pain  at  the 
instant  of  the  accident;  a  sudden  inability  to  move 
the  limb ;  a  preternatural  mobility  occurring  in  some 
particular  part;  a  crepitation  sometimes  distinct,  when 
the  two  fragments  are  rubbed  against  each  other; 
and  a  deformity,  which  may  be  considered  under  the 
threefold  relation,  of  length,  thickness,  and  direc- 
tion.* These  signs,  being  common  to  most  fractures, 

*  (La  longueur.^  Vepaisseur^  et  la  direction.)  That  is,  the 
thigh  may  be  shortea*  than  natural,  owing  to  the  ends  of  the 
broken  bone  overlapping  each  other ;  it  may  have  a  protube- 
rance on  one  side,  in  consequence  of  these  ends  being  separated 
or  displaced  laterally ;  or  the  dii^ection  of  the  limb  may  be 
changed,  by  a  bend  or  angle  being  produced  in  the  bone  at  the^ 
place  of  the  fracture.  Trans, 

29 


exhibit  but  few  circumstances  peculiar  to  those  of 
the  OS  femoris,  except  that  of  the  deformity.  Respect- 
ing this  circumstance,  in  particular,  it  is  essentially- 
necessary  to  possess  accurate  ideas,  because,  having- 
an  incessant  tendency  to  recur,  especially  in  oblique 
fractures,  it  must  constitute  a  primary  object  of  at- 
tention durmg  the  treatment. 

10.  It  may  be  laid  down  as  a  general  principle, 
that  all  fractures  of  the  os  femoris  ai'c  accompanied 
with  some  deformity ;  the  exceptions  to  this  rule  are 
too  few  to  be  worthy  of  notice.  If  this  deformity  be 
considered  in  relation  to  length,  it  will  be  found  that, 
in  oblique  fractures,  the  limb  is  always  shorter  than 
that  of  the  opposite  side,  a  circumstance  which  plainly 
points  out  an  overlapping  of  the  fragments.  But,  on 
examining  the  place  of  fracture,  it  is  easy  to  disco- 
ver, that  this  overlapping  aiises  from  the  inferior 
fragment  mounting  upwards  on  the  superior  one, 
which  itself  remains  immoveable.  Now,  what  power, 
but  the  contraction  of  the  surrounding  muscles,  can 
communicate  to  the  inferior  fragment  a  motion  from 
below  upwards?  Attached,  on  the  one  hand,  to  the 
pelvis,  and  on  the  other  to  tliis  fragment,  to  the  rotu- 
la,  the  tibiae,  and  the  fibula,  these  muscles  have  on 
the  former  their  fixed,  and  on  the  latter  their  move- 
able points,  and,  di^awing  the  leg,  the  knee,  and  the 
inferior  portion  of  the  thigh  upward,  they  produce 
the  displacement  and  shortening  either  mediately  or 
immediately.  In  this  displacement,  the  adductores, 
tlie  semi-tendinosus,  the  semi-membranosus,  the 
rectus  anterior,  the  rectus  internus,  &c.  are  the  prin- 
cipal agents* 


219 

11.  The  following  case  communicated  to  De- 
sault  by  a  surgeon,  who  had  been  formerly  his  pu- 
pil, proves  how  great  the  influence  of  this  cause  is; 
a  cause  which  is  indeed  generally  acknowledged,  but 
not  sufficiently  attended  to  by  practitioners,  with  a 
reference  to  permanent  extension.  It  is  this  that  in- 
duces me  to  relate  the  case. 

Case  I.  A  carpenter  falling  under  the  ruins  of 
his  scaffold,  was  immediately  taken  up  and  carried 
home,  where  a  surgeon  discovered  an  oblique  frac- 
ture of  the  OS  femoris,  but  without  any  displace- 
ment. The  thigh,  which  appeared  even  a  little  longer 
than  the  other,  was  fixed  in  an  apparatus  too  slack 
to  prevent  muscular  action.  Next  day,  the  length 
ofthe  thigh  was  the  same^  but  the  whole  extremity 
was  in  a  paralytic  state,  accompanied  by  an  entire 
inability  to  discharge  urine. 

The  moxa  was  proposed.  The  patient  being 
placed  in  the  position  directed  by  Pott,  for  fracture^ 
ofthe  OS  femoris,  the  fire  was  applied;  some  move- 
ments were  the  consequence;  the  application  being 
repeated  on  the  sixth  day,  the  muscles  instantly  re- 
covered their  power  of  action,  and  then  the  shorten, 
ing  of  the  limb  became  evident,  and  still  returning 
immediately  after  being  removed  by  extension, 
rendered  it  necessary  to  have  recourse  to  an  apparatus 
.calculated  for  permanent  extension. 

12.  In  this  case,  the  muscular  influence  is  evif- 
dent.  Indeed  the  shock  having  produced  a  tempo- 
rary suspension  of  the  excitability  of  the  part,  the 
fragments  remained  in  place  and  in  proper  contact 
with  each  other :  but  the  moxa  having  awakened  the 
excitability  again  in  the  muscles  of  the  thigh,  they 


220 

resumed  their  action  and  caused,  as  usual,  the  infe- 
rior fragment  to  mount  on  the  superior. 

13.  Hence  it  follows,  1st,  that  it  is  principally  to 
the  action  of  the  muscles  that  we  must  attribute  the 
displacement,  in  the  longitudinal  direction  of  the 
bone;  2dlv,  that,  as  that  action,  being  the  effect  of  an 
inherent  power,  is  constantly  exerted,  the  limb  must 
have  a  constant  tendency  to  this  displacement,  par- 
ticularly in  oblique  fractures,  where  the  two  extre- 
mities of  the  bone  represent  two  inclined  plains, 
which  readily  glide  along  each  other. 

14.  To  this  must  be  still  added  another  cause^ 
which  operates  injuriously  in  the  course  of  the  treat- 
ment. However  solid  the  bed  may  be  on  which  the 
patient  lies,  the  nates  or  buttocks,  being  the  most 
projecting  pait  of  the  body,  soon  form  a  depression 
in  it;  hence  arises  an  inclination  or  descent  of  the 
plain  or  surface  on  which  the  body  lies.  The  body 
therefore  sliding  doA\aiw^ai'ds,  pushes  before  it  the 
superior  fragment,  and  makes  it  overlap  the  inferior 
one.  In  consequence  of  this,  the  muscles,  being 
instated  by  the  points  of  the  bones,  increase  the  force 
of  their  contractions,  and,  as  we  have  already  obser- 
ved (10),  di'aw  the  inferior  fragment  upwards.  This 
double  movement  of  the  two  ends  of  the  bone  in 
contiTuy  directions,  produces  only  a  single  effect, 
namely,  the  overlapping  of  these  ends,  but  carries 
this  overlapping  to  a  higher  degree. 

15.  Transverse  fractures  are  less  exposed  to 
displacement,  in  the  longitudinal  direction  of  the 
bone,  because  the  fragments  when  in  contact,  sup- 
port each  other.  In  such  a  case,  the  inferior  fragment, 
drawn  by  the  muscles,  finds  a  point  of  resistance 


221 

against  the  superior  one,  while  the  latter,  when  pres- 
sed downward  by  the  weight  of  the  body,  pushes  the 
former  before  it,  and  thus  both  preserve  their  relative 
position. 

16.  A  deformity  of  the  fractured  os  femoris,  in 
the  direction  of  its  cross-diameter  or  thickness  (9), 
always  accompanies  that  in  its  longitudinal  direction, 
and  sometimes  exists  alone.  This  takes  place  when, 
in  a  transverse  fracture  the  two  ends  of  the  bone, 
losing  their  contact,  ai*e  carried,  the  one  outward,  and 
the  other  inward,  or  when  the  one  remains  in  its  place, 
while  the  other  is  separated  from  it.  In  such  a  case, 
the  superior  fragment  is  not,  as  in  the  preceding  one, 
immoveable  by  means  of  muscular  action;  because 
the  action  of  the  pectineus,  the  psoas,  the  illiacus, 
and  the  first  adductores,  derange  its  natural  direction, 
and  contribute  to  its  displacement. 

17.  The  deformity  of  the  limb,  in  relation  to  its 
direction,  m  other  words,  the  crookedness  of  the 
limb  (9)  is  either  the  result  of  the  stroke  which 
fractured  it,  or,  wliat  is  more  common,  of  the  ill 
directed  efforts  of  those  who  lift  and  carry  the  pa- 
tient, and,  by  an  improper  position,  bend  the  two 
fragments,  so  as  to  make  them  form  an  angle  with 
each  other.  Desault  was  once  called  to  a  patient, 
whom  he  found  seated  on  a  bed,  in  such  a  manner, 
that  the  upper  part  of  the  thigh  was  in  a  horizontal 
position,  and  the  lower,  hanging  with  the  leg  in  al- 
most a  perpendicular  one.  Doubtless  tlie  triceps  fe- 
moralis,  equally  attached  to  both  fragments,  bends 
them  by  its  contraction,  and  produces  a  change  in 
the  direction  of  the  limb. 


222 

18.  Whatever  may  be  the  kind  of  the  deformitj^, 
whether  in  a  longitudinal  or  latei'al  direction,  the  in- 
ferior fi'agment  may  either  preserve  the  natural  posi- 
tion in  which  it  is  placed,  or  experience  a  rotatory 
motion  on  its  axis  outwards,  which  is  a  common 
occurrence,  or  inwards,  a  circumstance  which  is  more 
rare.  This  rotation  always  renders  the  displacement 
more  serious,  and  ought  to  have  an  influence,  as  I 
shall  presently  obser\^e,  on  the  means  of  reduction. 

UV. 

OF   THE    PROGNOSIS. 

19.  Fractures  of  the  os  femoris,  tliough  seldom 
very  distressing,  in  common  cases,  from  any  acci- 
dents that  immediately  accompany  them,  are  some- 
times rendered  so,  by  inconveniences  which  are  the 
consequences  of  them,  M^hen  they  ai'e  oblique.  Celsus 
declared,  that  a  shortening  of  the  limb,  more  or  less 
considerable,  v.as  always  the  result  of  such  fractures. 
Most  authors  have  copied  and  repeated  this  assertion, 
and,  even  at  the  present  day,  tlie  opinion  is  advocated 
by  a  great  number  of  practitioners.  It  must  be  ac- 
knowledged, that,  if  we  compare  the  natural  powers 
that  ai'e  engaged  in  producing  displacement (10...  15), 
with  the  artificial  resistance  made  by  most  of  our 
forms  of  appai'atus,  we  will  perceive  that  there  is  bcf 
tween  the  two  forces  so  great  a  disproportion  in  point 
of  strength,  that  the  former  can  never  yield  to  the 
latter.  But,  is  it  in  the  nature  of  all  forms  of  appara- 
tus to  be  unable  to  overcome  the  force  of  the  displac- 
ing powers?  Cannot  an  equilibrium  be  established, 


223 

^o  as  to  retain  the  fragments  in  contact?  The  remain- 
der of  the  present  memoir  will  throw  some  light  on 
this  problem,  which  will  become  less  difficult  of  solu- 
tion, if  we  call  to  mind,  that  the  action  of  m.uscles, 
though  verj^  powerful  at  first,  diminishes  afterw^ards 
by  degrees,  in  consequence  of  their  being  kept  in  a 
state  of  permanent  extension ;  that  even  a  weaker 
power  may,  by  acting  constantly,  accomplish  ulti- 
mately, what  could  not  have  been  eifected  at  once,  by 
another  power  much  stronger,  if  only  momentarily^ 
applied;  and  that  compression  made  by  circular  ban- 
dages, tends  also  to  diminish  the  force  and  prevent 
the  action  of  muscles. 

Desault  has  cured,  at  the  Hotel- Dieu,  a  vast  num- 
ber of  fractures  of  the  os  femoris,  without  the  least 
remaining  deformity,  and  there  are  but  few  of  his 
pupils  who  have  not  witnessed  his  success,  some  in- 
stances of  which  will  be  cited  in  this  memou*. 

20.  It  is,  above  all,  from  the  well  combined  use- 
of  these  two  means,  the  extension  and  compression  of 
the  muscles,  that  that  success  was  derived.  The  ad- 
vantage of  extension,  in  diminishing  muscular  force, 
is  evident,  particularly  in  the  reduction  of  certain 
luxations,  those  of  the  humerus,  for  example,  where 
we  are  frequently  unable  to  succeed,  till  after  having- 
extended  the  muscles  for  a  longer  or  shorter  time. 

Fractures  of  the  rotula  and  of  the  olecranon,  pro'>c 
equally  the  utility  of  compression  in  effecting  the  same 
purpose;  for,  when  the  muscles  are  not  compressed 
by  a  bandage,  they  dravv*  the  fragment  up^^ards  v/ith, 
a  double  and  even  treble  force. 


224 

21.  Accidents  relating  to  Complications  of  the 
fracture,  such  as  sphnters,  wounds,  &c.  are  to  be 
classed  with  compound  fractures  in  general,  and  can- 
not be  treated  of  in  this  place. 

§V. 

OF   THE   REDUCTION. 

22.  Two  great  indications  enter  into  the  treatment 
of  fractures  in  general,  and  of  that  of  the  os  femoris 
in  particular;  namely,  to  bring  the  fragments  into 
proper  contact,  and  to  maintain  them  so.  Let  us  ex- 
amine each  of  these  in  all  their  details. 

Hippocrates,  and  every  practitioner  since  his  time, 
have  replaced  the  fragments  by  what  they  call  exten- 
sion, counter-extension,  and  coaptation.*  This  three- 
fold method,  though  sanctioned  by  long  usage,  and 
rendered  almost  venerable  by  age,  is  by  no  means 
jiecessary  at^l  times  in  practice,  as  will  presently  be 
observed.  Previously  to  having  recourse  to  it,  it  is 
necessary  to  place  the  patient  in  a  suitable  position. 
But  this  position  varies :  most  of  the  moderns  adopt, 
after  the  example  of  the  ancients,  a  horizontal  posi- 
tion :  so  that  the  thigh  may  be  extended  on  the  body, 
and  the  leg  on  the  thigh.  This  is  the  common  prac- 
tice at  present  in  France. 

23.  Pott  imagined,  on  the  contrary,  that  if  the 
lower  extremity  were  kept  in  a  half-bent  position,  the 
muscles,  being  more  relaxed,  would  offer  less  resist- 

*  A  term  of  nearly  the  same  import  with  ''conformation." 

Trans. 


^1 

^fce  t6  the  efforts  oF  the  extension :  he,  therefore, 
proposed  to  bend  the  leg  on  the  thigh,  and  the  thigh' 
On  the  pelvis,  and  to  lay  the  patient  on  his  side,  ai'' 
position,  which/  when  first  employed  in  reduction, 
■\^ais  to  be  continued  throughout  the  treatment,  during 
"which  it  wouicl  render  the  causes  of  displacement  less' 
active  (10...  15).  Bell  adopted  this  method,  which 
indeed  appears  to  be  generally  in  use  in  England. 

24.  But  the  difficulty  of  making  extension  and 
counter-extension,  with  the  limb  thus  situated,  the 
necessity  of  making  them  on  the  fractured  bone  itself, 
and  not  on  a  part  distant  from  the  fiticture,  such  as 
the  lower  part  of  the  leg;  the  impossibility  of  com- 
paring the  diseased  thigh  with  the  sound  one,  to  judge 
of  the  regularity  of  the  conformation ;  the  uneasiness 
occasioned  by  this  position,  if  long  continued,  though' 
it  may  at  first  appear  the  most  natural;  the  trouble- 
some and  painful  pressure  of  the  body  on  the  great 
trochanter  of  the  affected  side ;  the  derangements  to' 
which  the  flragments  are  exposed  when  the  patient 
goes  to  stool;  the  difficulty  of  fixing  the  leg  with 
sufficient  steadiness,  to  prevent  it  from  affecting  the 
OS  femoris  by  its  motions ;  the  evident  impractica- 
bility of  this  method,  when  both  thighs  are  broken; 
and,  finally,  experience,  which,  in  France,  has  been 
by  no  means  favourable  to  the  position  recommended 
by  Pott:  such  were  the  considerations,  which  deter- 
mined Desault  to  have  recourse  to  it  no  more,  after 
having  tried  it  on  two  patients,  in  one  of  whom  the 
limb  was  considerably  shortened,  notwithstanding  the 
most  scrupulous  attentions. 

30 


226^ 

25.  Besides,  all  that  is  gained  by  the  relaxation  of 
some  muscles,  is  lost,  by  the  tension  of  several 
others.  The  knee  cannot  be  bent  without  the  triceps 
flexor  being  brought  into  action ;  an  inconvenience 
the  more  serious,  as  this  muscle  acts  immediately  on 
both  fragments.  The  rectus  anterior,  though  relax- 
ed by  the  flexion  of  the  thigh,  will  be  throwTi  into  a 
state  of  tension  by  the  flexion  of  the  leg.  The  mus- 
cles aj;tached  posteriorly  to  the  upper  fragment,  and 
even  to  the  superior  part  of  the  lower  one,  will  also 
in  certain  positions  of  the  limb  be  rendered  tense. 

26.  Hence  it  follows,  that  there  can  be  no  just 
comparison  instituted  as  to  the  position  proper  for 
the  limb,  between  fractures  of  the  upper  and  those 
of  the  lower  extremities;  that,  in  the  latter,  the 
method  pursued  by  the  English  surgeons  presents  an 
aggregate  or  general  amount  of  inconveniences  so 
great  as  to  overbalance  that  of  its  advantages ;  and, 
that  the  position  directed  by  Hippocrates  and  the 
other  Greek  physicians  (22)  ought  to  be  adopted. 

27.  Having  determined  onr^e^  position,  the  ope- 
rator proceeds  to  extension  and  counter- extension, 
which  are  to  be  made  first  in  the  direction  of  the  limb 
as  deformed  or  altered  by  the  fi-acture,  but  must  be 
changed  afterwards  according  to  the  natural  direction 
of  the  thigh.  I  need  not  here  repeat  the  directions 
for  this  double  operation :  common  to  all  fractures, 
they  contain  notliing  particular,  in  relation  to  that  of 
the  thigh.  But,  on  what  part  should  extension  be 
made?  Petit,  Heister,  Duvemey,  and  all  their  pre- 
decessors, recommend  to  apply  the  means  or  powers 
for  making  extension  above  the  knee;  a  precept 


227 

which  is  still  to  be  found  in  the  surgical  department  of 
the  Encyclopedia.  A  strap  surrounding  the  lower 
part  of  the  thigh,  aided  by  another  placed  at  the  ancle, 
serves,  in  this  respect,  to  draw  the  inferior  fragment 
downward. 

28.  Dupouy  was  the  first  to  remark,  that  this 
practice  rendered  it  necessaiy  to  employ  great  force, 
and  that  it  would  be  better  to  make  extension  only 
on  the  foot.  To  this  consideration  Fabre  added 
that  of  the  inconvenience  of  the  pressure  made  on 
the  muscles,  a  pressure  which,  by  irritating  them 
and  making  them  contract,  multiplies  the  obstacles 
to  the  reduction. 

Desault  adopted  their  doctrine,  from  nearly  the 
same  views  of  the  subject,  introduced  it  into  the 
Hotel-Dieu,  and  the  success  which  attended  it,  in 
his  practice,  contributed  not  a  little  to  bring  it  into 
general  use. 

29.  For  the  purpose  of  making  extension,  he 
used  ^he  foot  as  a  lever  of  the  fii'st  kind.  The  two 
hands  of  an  assistant,  grasping  it  in  such  a  manner, 
as  to  make  the  fingers  cross  on  the  back  of  it,  while 
the  thumbs,  also  crossing  each  other,  corresponded 
to  the  sole,  represented  the  power;  the  articulation 
represented  the  centre  of  motion,  or  fulcrum,  and 
the  leg  together  with  the  louver  fragment,  the  resist- 
ance. The  requisite  motion  was  then  communicated 
to  the  foot,  and  in  that  way  was  the  extension  effected. 
This  mode  is  more  advantageous  than  that  usually 
employed,  where  the  hands  are  applied  to  the  lower 
extremity  of  the  leg ;  for  the  force  of  the  extending 
power  is  generally  in  the  inverse  ratio  of  its  distance 
fi'om  the  resistance  intended  to  be  overcome. 


^23 

30.  What  I  have  said  of  extension  (2i8),  applies 
also  to  counter-extension.  The  strap,  which  was  for- 
merly placed  for  this  purpose  in  the  groin  of  the  af- 
fected side,  by  compressing-  the  adductores,  and  the 
rectus  intemus,    produced  in  them  a  contraction, 
which,  by  drawing  the  lower  fragment  towards  the 
pelvis,  opposed  obstacles  to  the  reduction,  which  are 
seldom  experienced,  when,  like  Desault,  the  surgeon 
contents  himself  with  having  the  trunk  held  by  assisjt- 
ants,  either  exclusively  at  the  hips,  or  both  at  the 
hips  and  under  the  arm-pits.  The  resistance  being 
always  easily  overcome  in  this   affection,  renders 
it  unnecessary  to  have  recourse  to  more  powerful 
means. 

31.  Hippocrates  advises,  in  fractures  of  the  os 
femoris,  to  aid  extension  by  coaptation,  performed 
with  the  hand.  All  practitioners,  since  his  time,  have 
added  this  third  mancEuvre  or  process  to  the  two  first, 
namely,  extension  and  counter- extension.  But,  what 
effect  can  the  hands  produce,  in  most  cases,  on  the 
^one  through  the  thick  covering  of  the  soft  parts? 
Are  we  able  to  communicate  to  it  through  such  a 
mass  whatever  lateral  movement  we  please?  Being 
quite  lost  in  the  intervening  soft  parts,  will  our  efforts 
reach  the  bone,  in  the  direction  which  we  give  them? 
The  muscles  bring  the  fragments  into  contact,  much 
better  than  we  can,  as  soon  as  extension  has  removed 
their  overlapping.  Indeed,  if  well  executed  extension 
make  the  lower  fragment  return  along  the  same  tracl^ 
which  it  pursued  in  becoming  displaced,  it  will  then 
be  inevitably  brought  into  contact  with  the  upper 
one  by  the  contraction  of  the  muscles.  Besides,  in 


229 

most  oblique  fractures,  is  it  not  evident,  that  the 
lower  fragment  must  be  made  to  slide  from  above 
downwai'd,  on  the  inclined  plain  presented  by  the 
upper  one,  and  on  which  it  has  slided  from  below 
upward,  in  becoming  displaced?  Is  it  while  exten- 
sion is  making  that  coaptation  ought  to  be  perform- 
ed? Certainly  not:  because,  if  the  extension  be  well 
directed,  an  attempt  at  coaptation  v/ill  derange  it; 
and  if  it  be  not  well  directed,  its  course  ought  to  be 
changed.  Is  it  after  extension  is  finished  that  recourse 
ought  to  be  had  to  coaptation?  By  no  means :  because 
if  there  be  then  any  remains  of  deformity,  it  must  be 
owing  to  extension  having  been  improperly  directed. 
The  remedy,  therefore,  is,  to  renew  the  extension, 
and  direct  it  properly. 

32.  Hence,  it  follows,  in  general,  that  coaptation 
is  here  a  feeble  assistant  towards  reduction ;  that  if  it 
renders  any  service,  it  is  only  in  cases  of  displacement 
lateraiiv,  or  in  the  direction  of  the  cross-diameter  of 
the  bo  .e ;  and  that  it  is  by  giving  the  proper  direc- 
tion to  extension,  by  managing  it  according  to  the 
disposition  of  the  muscles,  and  by  knowing  when  to 
augment  and  when  to  slacken  it,  that  the  fragments 
are  brought  into  regular  contact. 

33.  If  the  inferior  fragment  has  experienced  a 
rotatory  motion  on  its  own  axis  outwards  or  inwards 
(18),  the  assistant  ought,  in  making  extension,  to 
turn  the  limb  very  gradually  in  the  opposite  direction. 

34.  Extension  was  formerly  attended  with  diffi- 
culties, which  are  rarely  met  Vvdth  at  the  present  day. 
Oftentimes,  if  we  give  credit  to  authors,  it  \vas  alto- 
gether useless  to  endeavour,  in  the  first  instance,  to 


230 

reduce  the  fracture,  and  restore  the  limb  to  its  natu- 
ral length,  as  the  contraction  of  the  muscles  rendered 
the  operation  absolutely  impracticable.  Hence,  appli- 
cations of  a  soothing  and  sedative  nature  were  em- 
ployed, previously  to  an  attempt  at  reduction.  The 
following  circumstances  have  been  assigned  as  the 
cause  of  these  difficulties.  The  upper  strap,  irritat- 
ing and  drawing  upwards  the  adductores  and  the 
rectus  intemus,  drew  the  lower  fragment  in  the  same 
direction,  while  the  semi-tendinosus,  semi-membra- 
nosus,  biceps,  &c.  being  drawn  downwards  by  the 
lower  strap  applied  over  them,  di'ew  the  pelvis  also 
downwards,  and,  consequently,  the  superior  fragment 
connected  with  it.  From  this  double  action  arose  a 
double  motion  directly  opposed  to  that  which  ought 
to  be  produced  by  extension. 

35.  There  are  still  cases,  where  the  muscles,  in 
consequence  of  being  irritated  by  projections  or 
points  of  bone,  by  the  efforts  of  the  assistants,  and 
by  a  morbid  state  of  the  nerves,  increase  their  con- 
traction to  such  a  pitch  that  no  practicable  force  can 
bring  the  fragments  into  apposition.  What  means  are 
then  to  be  employed?  All  those,  in  general,  that  di- 
minish irritability,  varied  according  to  circumstances, 
such  as  diet,  venesection,  &c.  In  such  cases,  Desault 
obtained  the  most  happy  effects,  by  placing  the  limb 
in  a  state  of  continued  extension ;  fatigued  by  the 
peiTuanent  tension  in  which  they  ai'e  thus  kept,  the 
muscles  relax  by  degrees ;  their  force  diminishes ;  at 
length  they  yield,  and  the  reduction  is  accomplished. 


231 


§VI. 

OF     THE    MEANS    OF    MAINTAINING     THJE 
REDUCTION. 

36.  The  mere  reduction  of  a  fracture  of  the  os 
femoris,  is  but  one  step  towards  the  cure.  In  this, 
more  than  in  the  fracture  of  any  other  bone,  causes 
which  act  incessantly  (13)  tend  to  subvert  the  mo- 
mentary work  of  art;  it  is  here,  then,  in  paiticular, 
that  means  ought  to  be  devised  for  maintaining  this 
work.  But,  the  first  of  these  means  is  a  suitable  po- 
sition of  the  limb.  I  have  already  mentioned  the 
inconveniences  that  result,  both  as  to  the  reduction 
and  subsequent  treatment,  from  that  proposed  by  Pott 
(24... 26).  The  patient  must,  then,  be  laid  horizon- 
tally on  a  plain  exactly  even,  and  not  capable  of 
being  affected  or  rendered  uneven  by  the  weight  of 
the  body.  Instead  of  feather  beds  generally  used  in 
other  cases  at  the  Hotel-Dieu,  Desault,  in  cases 
of  fractures,  substituted  firm  and  hard  mattresses, 
\fhich,  not  sinking  in  the  least,  by  the  pressure  of  the 
body,  give  no  cause  to  apprehend  those  continual 
displacements,  to  which  a  soft  bed  exposes  the  pa- 
tient. These  mattresses  supersede  the  advice  of 
certain  authors  who  direct  a  plank  to  be  placed  under 
the  patient. 

37.  The  second  means,  not  less  efficacious  than 
the  first,  consist  in  the  forms  of  apparatus,  in  which  the 
limb  is  placed,  and  which,  being  di^erently  modified 
according  to  the  fancies  of  their  different  authors,  pre- 
sent us  with  an  assemblage  of  various  splints,  corn- 


23^ 

presses,  Sec.  To  appreciate,  with  accuracy  and  correct- 
ness, the  advantage  and  disadvantage  of  these,  let  us 
first  unfold  the  curative  indications  which  they  ought 
to  fulfil ;  we  will  then  compare  their  mode  of  action 
with  these  indications,  from  whence  will  result,  as 
necessary  inferences,  the  object  of  our  research. 

38.  The  intention  of  every  form  of  apparatus 
being,  to  prevent  the  displacement  of  the  fragments, 
the  causes  of  this  displacement  ought  to  be  the  basis 
or  foundation  of  its  mechanism  and  construction. 
But  these  causes  in  the  present  case  are,  1st,  the 
muscular  action  di'awing  the  inferior  fragment  up- 
wards (10);  2dly,  the  weight  of  the  body  pushing 
the  superior  fragment  downwards  (14);  whence 
every  form  of  apparatus  intended  to  keep  the  os 
femoris  in  place  when  fractured  obliquely,  ought, 
1st,  to  draw  the  lower  fragment  downward  and  retain' 
it  there ;  2dly,  to  draw  and  retain  upwards  the  supe- 
rior fragment,  and  the  trunk  which  bears  on  its  up- 
per end.  This  principle  is  applicable  generally,  and 
subject  only  to  a  few  exceptions  which  I  shall  notice 
when  treating  of  transverse  fractures,  where  the  dis- 
placement is  lateral,  or  in  the  direction  of  the  cross- 
diameter  of  the  bone,  or  where  no  displacement  at 
all  exists.  3dly,  The  apparatus  must  also  be  so  con- 
structed as  to  prevent  the  rotatory  rriotions  of  the 
lower  fragment  (18),  and  secure  the  immobility  of 
the  limb,  lest  by  means  of  some  motion  being  com- 
municated to  it,  the  fragments  might  be  deranged. 


233 


§  VII. 

OF    THE    MANNER    IN    WHICH    THE    DIFFERENT 
PIECES    OF    THE    APPARATUS    ACT. 

39.  If  to  these  indications  we  compare  the 
mode  of  action  of  the  different  pieces  that  unite  in 
composing  our  common  forms  of  apparatus  which 
do  not  make  permanent  extension,  such  as  com- 
mon bandages,  spUnts,  compresses,  bolsters,  &c. 
we  will  perceive  that  they  are  but  ill  calculated  to 
fulfil  them:  and  first  of  bandages.  Whether  the 
common  roller,  or  the  eighteen-tailed  bandage  be 
employed,  their  mode  of  operation  is  the  same :  their 
only  action  is,  to  add  a  second  exterior  and  artificial 
covering  to  the  natural  cutaneous  and  aponeurotic 
covering  of  the  thigh ;  to  press  against  the  fragments 
the  muscles  which  form  for  them  a  kind  of  natural 
case  intended  to  keep  them  in  apposition;  and  to 
augment,  by  this  pressure,  the  lateral  resistance  of 
the  soft  parts.  By  this  contrivance,  lateral  displace- 
ments will,  in  part,  be  well  guarded  against,  and,  in 
this  respect,  these  bandages  are  useful  in  transverse 
fractures.  But  what  is  there  in  them  to  prevent  the 
two  inclined  plains  of  an  oblique  fracture  from  sliding 
on  each  other?  What  provision  is  there  in  them  to 
secure  the  limb  fi^om  the  effects  of  motions  and 
shocks  which  may  be  accidentally  impressed  on  it 
from  without?  Will  the  pelvis  be  kept  steady  by 
tliem?  or  will  muscular  action  be  sufficiently  checked 
and  kept  under  by  them?  The  force  of  the  muscles 

will  indeed  be  slightly  diminished  by  means  of 

31  ^ 


234 

compression;  and  to  make  this  compression  is  tlie 
principal  use  of  these  bandages  in  oblique  fractures. 
But  will  mere  compression  be  sufficient  to  prevent 
a  displacement  in  the  longitudinal  direction  of  the 
bone,  particularly  if  the  rollers  be  slack,  as  certain 
practitioners  recommend,  on  the  ground  of  the  fal- 
lacious theory  of  Duhamel,  who  conceived,  that  a 
constriction  too  tight,  would  injure  the  action  of  the 
periosteum,  which,  according  to  him,  is  the  sole 
agent  in  the  formation  of  callus?  So  much,  then,  for 
bandages,  whose  only  use  is  to  prevent,  by  compres- 
sion, the  swelling  of  the  limb,  and  to  diminish,  in 
some  degree,  the  contraction  of  the  muscles,  which 
they  press  against  the  fractured  bone, 

40.  These  remarks  apply  equally  well  to  the  use 
of  compresses ;  which  make  but  a  very  feeble  resist- 
ance against  a  powerful  cause,  and  cannot  be  consi- 
dered as  any  obstacle  whatever  to  displacement. 
What  can  be  said  of  those  surgeons  who,  from 
servile  attachment  to  a  particular  form  of  apparatus,^ 
do  not  consider  a  fracture  as  reduced,  unless  a  cer- 
tain quantity  of  compress  secured  by  a  given  quan- 
tity of  roller,  be  applied  on  the  limb.  Servile  imita- 
tators  in  an  ai't  which  calls  for  genius  in  its  votaries, 
they  are  only  capable  of  following,  without  reflection 
or  judgment,  the  steps  of  their  predecessors. 

41.  Bandages  will  do  nearly  as  much  harm  as. 
good  in  fractures  of  the  os  femoris,  if,  as  was  prac- 
tised by  the  ancients,  they  be  formed  by  a  single  roller 
surromiding  the  limb:  in  such  a  case,  the  limb  being 
necessarily  raised  up  at  each  time  of  their  reapplica- 
tiouj  will  be  exposed  to  continual  displacements* 


23B 

Hence  the  ingenious  idea  of  applying  to  simple  frac- 
tures of  the  lower  extremities  the  eighteen-tailed  ban- 
dage, invented  for  compound  fractures,  and  by  means 
of  which  the  thigh  may  be  suffered  to  remain  at  rest. 
But  to  this  bandage  belongs  also  an  inconvenience. 
The  pieces  w^hich  compose  it,  being  stitched  together, 
cannot  be  separated,  and  if  one  of  them  be  soiled  they 
must  all  be  changed.  Hence  the  superiority  of  the 
bandage  of  slips,  knov/n  in  former  times,  and  engrav- 
ed by  Scultel,  but  long  since  forgotten,  till  Desault 
revived  the  use  of  it,  and  adopted  it  exclusively,  both 
in  simple  and  in  compound  fractures. 

42.  Splints  of  different  kinds,  which  form  the  se- 
cond division  of  the  pieces  of  apparatus,  used  for 
fractures  of  the  os  femoris,  have  the  advantage  of 
fixing  the  limb  in  a  solid  and  firm  manner,  and  secur- 
ing  it  from  any  displacement  that  might  result  from 
jolts,  or  muscular  contraction,  arising  from  the  inat- 
tention of  patients :  these  prevent,  more  effectually 
than  bandages,  any  displacement  laterally,  and,  on  this 
account,  their  use  is  sufficient,  even  without  exten- 
sion, in  transverse  fractures :  they  also  prevent,  par- 
ticularly if  they  be  made  of  wood,  the  rotatory  motion 
of  the  thigh  either  outwards  or  inwards  (18).  But  if 
the  division  be  oblique,  Vv^ill  they  prevent  the  gliding 
of  the  fragments  over  one  another,  and  the  consequent 
shortening  of  the  limb?  They  can  evidently  produce 
this  effect  in  no  other  way,  than  by  the  forcible  pres- 
sure made  by  the  pieces  of  apparatus,  paiticulai'ly  by 
the  straps  or  bandages  that  secure  the  splints,  and 
then,  to  make  effectual  resistance,  it  would  be  neces- 
sary to  apply  them  with  such  a  degree  of  tightness  as 


256 

would  endanger  the  life  of  the  limb.  Will  splints 
prevent  the  trunk  from  sinking  downwards,  and  push- 
ing the  superior  fragment  before  it?  Will  they  pre- 
vent the  muscles  from  acting  on  the  lower  fragment? 
Can  they,  in  a  word,  fulfil  all  the  indications  formerly 
pointed  out  (28)?  Certainly  they  cannot.  Splints, 
then,  are  calculated  only  to  prevent  displacement  in 
the  lateral  or  cross  direction  of  the  bone,  and  to  se- 
cure, better  than  bandages,  the  immobility  of  the  limb. 
Whence  it  follows,  that  they  ought  not,  in  this  case, 
to  be  confined  to  the  thigh  alone,  but  should  extend 
to  the  leg,  whose  movements,  if  communicated  to  the 
OS  femoris,  may  derange  the  contact  of  the  ends  of  the 
bone.  The  neglect  of  this  precaution,  contributed 
formerly  not  a  little  to  displacement  and  deformity. 

43.  In  former  times  a  kind  of  splints  was  in  use, 
w^hich  were  made  by  securing  bundles  of  straw  round 
sticks  proportioned  in  length  to  the  length  of  the  limb 
to  which  they  were  to  be  applied.  But  as  these,  from 
being  of  a  round  or  cylindrical  form,  touched  the  limb 
with  but  a  nan^ow  surface,  they  did  not  retain  the 
fracture  with  sufficient  firmness.  They  were,  there- 
fore, very  properly  exchanged  for  flat  and  sti'ong 
v/ooden  splints,  (such  as  Desauit  used)  which  retain 
the  fracture  much  better,  in  consequence  of  present- 
ing to  the  limb  a  broad  surface,  and  thereby 'render- 
ing it  in  some  measure  immoveable. 

44.  The  bolsters  for  filling  up  interstices,  being 
less  intended  to  prevent  displacement,  (in  which  re- 
spect they  are,  notwithstanding  useful)  than  to  guard 
the  limb  from  the  immediate  pressure  of  the  splints, 
usually  consist  of  several  folds  of  old  linen ;  this  is  the 


237 

form  adopted  at  the  Hotel-Dieu ;  but  to  these  Desault 
preferred  small  pallets  or  bags  filled  with  chaff,  which, 
fashioned  according  to  the  form  and  disposition  of  the 
limb,  may,  at  the  pleasure  of  the  surgeon,  be  made 
thicker  or  thinner,  to  suit  the  inequalities  of  the  sur- 
face, in  consequence  of  the  ease  with  which  the  chaff 
may  be  moved  from  one  part  of  the  bag  to  another. 

45.  From  the  foregoing  examination  of  the  action 
of  bandages  and  splints,  it  appears,  that  the  common 
apparatus,  formed  by  their  union,  but  not  calculated 
to  effect  a  permanent  extension,  may  perhaps  answer 
in  cases  of  transverse  fractures,  which  indeed  but 
rarely  occur,  but  ai'e  always  insufficient  when  the 
division  is  oblique,  because  they  cannot  fulfil  the 
double  indication  of  drawing  the  inferior  fragment 
down,  and  retaining  the  superior  one  up  (38). 

§  VIII. 

OF   PERMANENT   EXTENSION,   AND   THE   MEANS 
OF    EFFECTING    IT. 

46.  By  what  means  then  can  this  indication  be 
effectually  fulfilled?  By  that  which  will  perpetuate, 
throughout  the  whole  treatment,  the  action  of  those 
means  by  which  reduction  was  effected;  by  that 
which,  to  the  ever  active  power  of  the  muscles,  will 
oppose  a  resistance  constant  in  its  action;  by  that 
which,  forming  on  the  exterior  of  the  thigh  a  kind  of 
artificial  muscle,  may  become  an  antagonist  to  the 
natural  muscles  of  the  part,  and  neutralize  their  ef- 
forts, by  acting  in  a  contrary  direction,  and  which, 
by  pushing  up  the  pelvis  and  retaining  it  there,  may 


238 

prevent  it  from  being  pushed  downward  by  the 
weight  of  the  trunk  (14).  But  what  other  mean  than 
that  of  permanent  extension,  unites  these  advantages? 
Whatever  form  of  apparatus  may  be  employed  to  ob- 
tain it,  it  is  permanent  extension  alone  that  can  pre- 
vent the  displacement,  because  it  alone  is  founded 
on  principles  calculated  to  meet  and  obviate  the  causes 
by  which  displacement  is  produced. 

47.  The  ancients,  though  less  informed  than  we 
are  respecting  the  nature  of  these  causes,  knew  bet- 
ter how  to  appreciate  their  effects.  All  their  forms  of 
apparatus  made  a  permanent  extension,  a  measure 
which  has  been  abandoned  by  most  of  the  moderns, 
and  regarded,  even  at  present,  in  France,  by  a  great 
number  of  practitioners,  as  always  dangerous,  and 
seldom  useful.  Let  us  set  in  opposition  to  the  vain 
fears  which  it  inspires,  a  few  thoughts,  and  much 
experience. 

48.  It  is  from  the  very  object  which  is  proposed 
to  be  attained,  that  the  first  difficulties  arise.  What 
must  we  think  of  a  limb  in  a  state  of  preternatural 
tension,  where  all  the  parts  being  overstretched  must 
experience  an  uneasiness  not  to  be  supported?  I  an- 
swer, that  it  is  not  a  preternatural  elongation  that  ex- 
tension produces ;  on  the  contrary,  being  intended 
to  prevent  a  preternatural  shortening,  it  has  for  its  ob- 
ject to  restore  the  parts  to  their  ordinary  state,  and  to 
give  to  the  muscles  their  habitual  degree  of  tension, 
by  opposing  such  contractions  in  them  as  are  not  ha- 
bitual: under  this  point  of  view,  it  performs,  in  rela- 
tion to  the  muscles,  those  very  functions  which  are 
discharged  by  the  bone  itself,   when  sound  and  un- 


239 

broken,  as  is  fully  experienced  by  all  patients,  when 
the  apparatus  is  applied.  Its  use  not  only  does  not 
increase  pain,  but  is  alone  calculated  to  diminish  it^ 
because,  by  bringing  the  fragments  into  apposition, 
it  prevents  the  soft  parts  from  being  irritated  by  the 
points  of  the  bones. 

49.  Is  the  swelling  of  the  limb  to  be  dreaded,  as 
some  pretend?  But  whence  can  this  swelling  arise? 
From  the  over- stretching  of  the  paits?  I  have  already 
proved  that  they  are  not  over- stretched.  From  the 
pressure  of  the  straps?  Perhaps  this  cause  might  pro- 
duce a  swelling,  if,  as  formerly,  it  were  applied  above 
the  knee;  but,  by  placing  it,  as  Desault  did,  near  to 
the  ancle,  by  surrounding,  with  a  thick  compress^ 
the  lower  part  of  the  leg,  where  the  straps  pass,  and 
by  securing  the  foot  with  a  tight  bandage  under  the 
straps,  if  their  action  be  dreaded,  this  fear  must  be 
done  away;  and,  besides,  experience,  which  is  the 
only  true  test  of  the  dangers  of  a  process,  by  no 
means  justifies  the  apprehension.  The  venas  saphense 
and  the  absorbents  that  accompany  them,  are  free 
from  the  compression,  which  bears  principally  on 
the  tendo  Achiilis,  and  the  malleoli. 

50.  What  shall  we  say  in  reply  to  the  censure 
thrown  on  the  process  of  permanent  extension,  in  the 
memoirs  of  the  academy,  where  it  is  charged  with 
having  been  oftentimes  productive  of  ulceration  and 
even  gangrene,  in  consequence  of  the  pressure  of  the 
upper  strap?  What  method  can  escape  censure,  if  it 
be  unskilfully  pursued?  What  process  will  not  be 
injurious,  if  mutilated  and  ill  managed  by  ignorance 
or  a  want  of  discretion?  To  represent  the  thing  pro- 


240 

perly,  let  us  suppose  the  worst :  a  circular  bandage, 
in  consequence  of  being  drawn  too  tight,  produces 
mortification  in  the  subjacent  parts;  must  circular 
bandages  be  on  this  account  entirely  rejected?  An 
unskilful  hand,  in  an  operation  for  cancer,  opens  the 
axillary  artery;  must  we  therefore  cease  to  search 
under  the  arm-pit  for  schirrous  glands? 

51.  Permanent  extension  is,  say  some,  insuffi- 
cient to  overcome  muscular  action ;  it  is  opposing  to 
a  power  equal  to  1000,  a  resistance  equal  to  only  100. 
But  this  force  of  the  muscles,  which  is  oftentimes  so 
great  at  the  time  of  reduction,  diminishes  gradually, 
by  the  pressure  of  the  bandages,  by  the  immobility 
.of  the  limb,  and,  above  all,  by  long  continued  exten- 
sion ;  for  a  continued  effort  equal  to  10,  will  soon 
perform  what  could  not  be  effected  by  a  temporary 
exertion  of  a  force  equal  to  100.  Let  us  pass  over 
tlie  more  minute  objections  made  against  permanent 
extension,  and  search  among  the  different  modes  of 
performing  it,  that  to  which  practitioners  ought  to 
give  a  preference. 

52.  We  may  throw  into  two  classes  the  general 
modes  proposed  by  different  authors  for  effecting 
permanent  extension.  Under  the  one  are  included 
those  modes  requiring  simple  means,  such  as  straps, 
splints,  &c.  while  the  other  embraces  such  as,  from 
being  complex,  necessarily  call  for  the  use  of  different 
machines. 

53.  In  the  first  class  are  comprehended: 

1st,  The  method  employed  in  the  first  instance 
by  the  Arabians,  adopted  afterwards  by  their  suc- 
cessors in  medicine,  and  proposed,  at  a  still  later 
period,  by  Petit,  Heister,  and  Duverney,  and  which 


241 

consists  in  fixing,  at  the  head  and  foot  of  the  bed, 
during  the  whole  treatment,  straps  intended  for  the 
purpose  of  extension. 

2dly,  The  mode  of  extension,  adopted  by  many 
practitioners,  which  consisted  in  suspending  to  a  strap 
fixed  at  the  knee,  and  reflected  over  some  suitable 
body,  a  weight  proportioned  to  the  power  of  the 
cause  which  it  was  intended  to  combat. 

3dly,  The  ingenious  idea  of  Bruninghausen,  who> 
confining  by  a  kind  of  stirrup,  the  diseased  leg 
against  the  sound  one,  made  the  latter  serve  as  a 
splint  to  retain  the  fi-actured  limb  on  its  proper  line, 
and  thus  preserve  its  natural  length. 

4thly,  Under  this  class  also  must  we  an-ange  the 
Hffieans  employed  by  Desault,  and  which  we  will 
presently  describe. 

54.  The  second  class  of  means  invented  for  the 
purpose  of  making  permanent  extension,  in  fi^ac- 
tures  of  the  thigh,  comprehends: 

1st,  The  Glossocome,  the  bed  of  Hippocrates,* 
and  other  machines,  used  by  the  ancients,  to  effect 
a  reduction,  in  fractures  of  the  os  femoris,  and,  at  the 
same  time,  to  maintain  the  reduction,  by  being  left 
on  the  limb. 

2dly,  Numerous  machines,  invented  for  the 
purpose  of  suspending  a  weight  intended  to  make 
extension.    These  have  been  differently  varied  and 

*  (Le  lit  d'Hipfiocrate.)  As  many  of  the  machines  men- 
tioned here  have  probably  never  been  seen  in  this  country, 
and  as  there  is,  perhaps,  scarcely  one  of  them  used,  at  pre-^ 
sent,  in  any  country,  I  shall  not  consume  the  time  of  the  reader 
by  ti'oubling  him  with  descriptions  of  them.  Teaks. 

32 


242 

modified,  more  by  the  imagination  than  the  judgment. 
Engravings  of  some  of  them  are  to  be  found  in 
Scultet,  FabriciusofHilden,  Pare,  Sec. 

34ty,  The  machine  of  Bellocq^  proposed  to  the 
Academy  of  Surgeiy,  a  description  of  wliich  is  con- 
tained in  their  memoirs,  and  which  possesses  art 
advantage  not  fcnapd,  in  the  others,  namely,  that  ol 
taking  its  point  of  extension  at  the  IctiWier  part  of  the 

leg. 

4thly,  The  machine  of  Nook,  surgeon  at  Nor- 
wich, improved  by  Aitkin,  an  engraving  of  which  is 
given-  by  Bell. 

5thly,  A  new  Glossocome,  published  in  the 
works  of  Manne,  and  a  great  number  of  other  ma- 
chines, the  ephemeral  offspring  of  the  genius  of  their 
authors,  the  utility  of  which  experience  has  seldom 
confirmed,  and  which  were  even  deacL-born  in  the 
opinion  of  practitioners.  I  barely  mention  these, 
because  a  circumstantial  description  of  them  would 
lead:  me  from  my  subject. 

5-5n.  We  may  discover- at  a^  single  glance  the  com- 
parative merits  of  these  two  classes  of  apparatus. 
Extension  produced  by  simple  means,  such  as  straps, 
splints,  &c.  (50),  may  at  all  times,  and  under  all  cir- 
eumstances,.  be  had  recourse  to ;  because  the  means 
necessary  for  making  it  may  always  and  every  where 
be  found.  Are  we  desirous,,  on  the  other  hand,  of 
having  recourse  to  machines  (54)?  These  are  seldom 
at  hand,  and  oftentimes  not  to  be  obtained :  the  ex- 
pense attending  the  purchase  of  them,  prevents  most 
surgeons  fi^om procuring  them.  They  no  doubt  pos- 
sess the  advantage  of  multiplying  forces,  and  render- 


243 

ing  them  more  powerful :  but,  I  iiave  already  said 
(51),  that  a  gentle  resistance,  if  long  continued,  is 
sufficient  to  overcome  at  length  the  contraction  of  the 
inuscles,  tliough  at  first  extremely  active  and  ener- 
getic. 

56.  In  the  first  point  of  view.,  the  first  class  of 
ttieans  is  doubtless  preferable  to  the  second.  But 
they  both  partake  generally  of  the  inconvenience  of 
placing  the  point  of  extension  above  the  knee.  I  have 
already  mentioned  the  effects  which  this  produces  with 
respect  to  muscular  action,  at  the  time  of  the  reduc- 
tion (28).  To  the  injurious  effects  there  stated  may  be 
added  the  swelling  of  the  limb,  arising  from  the  com- 
pression made  by  the  straps,  the  disadvantage  of  the 
mobility  of  the  leg,  which  is  not  fixed,  and  the  mo- 
dons  of  which,  being  communicated  to  the  thigh, 
naay  separate  the  fragments  after  they  have  been, 
brought  into  apposition.  Further,  the  straps  may 
readily  slip  down  over  the  knee,  and  thus  leave  the 
fragments  subject  to  the  mischievous  influence  of 
muscular  contraction. 

57.  To  these  general  disadvantages,  add  those 
peculiar  to  each  form  of  apparatus,  which  are  too  te- 
dious to  be  detailed  at  present,  and  you  will  perceive, 
that  the  little  success  hitherto  obtained  from  continued 
extension,  is  owing,  not  to  the  nature  of  the  measure 
itself,  but  to  the  manner  of  employing  it,  and  that,  in 
the  present  case,  as  in  cases  of  fractured  clavicles, 
another  step  towards  perfection  remained  to  be  made. 

58.  Desault,  in  the  first  instance,  attempted  only 
to  improve  the  ancient  process,  which  consisted  in 
fixing  the  straps  for  extension  to  the  foot  and  head  of 


244 

the  bed.  He  remedied  the  inconvenience  of  fixing 
the  straps  at  the  knee,  by  doing,  throughout  the  whole 
treatment,  what  Fabre  and  Dupouy  did  only  at  the 
time  of  reduction  (29) ;  that  is,  he  placed  the  seat  c^ 
extension  at  the  foot.  The  hold  for  counter-extension 
was  also  changed.  This  he  made  by  a  bandage  for 
the  body,  fastened  round  the  breast,  and  drawn  only 
moderately  tight,  lest  it  might  impede  the  patient's 
respiration.  The  rest  of  the  apparatus  was  nearly  as 
I  shall  presently  describe. 

59.  This  was,  for  a  long  time,  the  only  apparatus 
which  Desault  used.  He  introduced  it  into  the  Hotel- 
Dieu,  after  having  employed  it  at  the  hospital  of  Cha- 
rity, with  great  success.  In  the  mean  time,  the  ut- 
most care  and  attention  were  here  indispensable: 
every  day  it  was  necessary  to  examine  the  rollers  se- 
veral times,  as  they  readily  became  relaxed.  The 
pelvis,  not  being  well  secured,  could  communicate 
motion  to  the  fracture :  it  was  difficult  to  raise  the 
patients  to  the  close-stool.  Besides,  the  slightest 
disease  of  the  chest,  rendered  the  pressure  of  the  body- 
bandage  insupportable.  It  was  this  very  inconveni- 
ence which,  having,  in  a  certain  case,  rendered  the 
preceding  apparatus  inadmissible,  suggested  to  De- 
sault the  following  one. 

60.  This  consists,  to  speak  in  general  terms,  in 
taking  the  points  of  extension,  above,  on  the  tubero- 
sity of  tlie  OS  ischium  of  the  diseased  side,  and 
below,  on  the  malleoli;  in  securing  the  straps  or 
rollers,  destined  for  making  extension,  on  the  two 
ends  of  a  strong  splint,  placed  along  the  outside  of 
the  limb;  and  in  converting,  so  to  speak,  the  pelvis. 


245 

the  thigh,  the  leg,  and  the  foot  into  one  entire  and 
solid  piece. 

The  pieces  which  compose  it  are,  1st,  A  com- 
mon junk-cloth*  (FFF  plate  II.),  accommodated  to 
the  size  of  the  limb  and  the  splints :  2dly,  a  ban- 
dage for  the  body  (BB)  and  one  passing  under  the 
thigh  (H)  to  secure  the  first  on  the  side  opposite  to 
the  fracture :  3dly,  three  stiff  splints,  an  inch  and  a 
half  wide,  the  external  one  of  which  (AA)  being 
very  strong,  must  be  long  enough  to  extend  from 
the  spine  of  the  ileum,  to  the  distance  of  four 
inches  below  the  sole  of  the  foot.  This  splint  is 
hollowed  out  or  notched  at  its  lower  end,  and 
has  a  mortise  in  it  a  little  higher  up.  The  upper 
splint  (CC)  occupies  the  space  included  between 
the  fold  of  the  groin  and  the  upper  part  of  the  knee : 
and  the  internal  one,  which  reaches  from  the  upper 

(*  Drafi-fanon.)  This  is  a  piece  of  linen  or  muslin  (De- 
sault  appears  to  have  used  flannel,  which  is  not  however  so 
good)  spread  under  the  broken  limb,  reaching  in  length  from 
one  end  of  it  to  the  other,  and  wide  enough  to  go  about  twice 
round  it.  It  is  to  be  folded  at  its  edges  several  times  round  the 
internal  and  the  long  external  splints,  in  order  to  retain  them 
the  better,  and  make  them  bear  with  more  steadiness  and  ad- 
vantage on  the  limb.  The  junk-cloth  and  these  two  splints, 
when  properly  applied,  form  a  kind  of  soft  elastic  case,  in 
which  the  limb  rests.  This  case  is  of  service  in  securing  the 
bolstt-rs  in  their  places.  The  junk-cloth  is  the  outside  piece  of 
the  apparatus,  except  the  bits  of  tape  which  go  round  and  se- 
cure the  whole.  In  arranging  the  different  pieces,  therefore, 
on  the  bed  or  mattress,  v/here  the  patient  is  to  lie,  the  surgeon 
places  the  tapes  first,  the  junk-cloth  next,  the  bandage  of  strips 
next,  and  so  on,  in  an  order  the  reverse  of  thr^t  in  which  he 
afterwards  applies  them  on  the  limb.  Tr.a-ns. 


B4B 

mid  internal  fold  of  tlie  thigh,  to  the  sole  of  the  foot*. 
4thiy,  three  bolsters,  an  external,  an  internal,  and  aii 
upper  one  (d  d  d  d)  consisting  of  small  bags  of 
chaff:  5thly,  a  bandage  of  strips  (EE)  accommodated 
as  to  number  to  the  circumstances  of  the  case, 
separate  from  one  another,  each  three  inches  broad, 
and  long  enough  to  go  twice  round  the  limb,  ar- 
ranged from  below  upwards,  and  overlapping  each 
other,  about  one  third  of  their  breadth:  6thly,  one 
long  and  two  circular  comprcsses,  intended  to  be 
applied  immediately  on  the  limb  next  to  the  skin : 
7thly,  two  strong  rollers  (g  g  and  L)  intended  for 
extension  and  counter- extension,  at  least  an  ell  and 
a  half  long:  8thly,  one  long  and  thick  compress,  and 
a  sufficient  number  of  bits  of  tape. 

61.  Every  thing  being  ready,  previously  to 
putting  the  patient  to  bed,  the  pieces  of  apparatus 
are  to  be  airanged  on  that  part  of  the  bed  corres- 
ponding to  the  fractured  thigh,  in  the  order  in 
which  they  are  to  be  successively  applied.  If  the 
patient  has  been  already  laid  in  the  place  where  he  is 
to  remain,  the  limb  must  be  raised  with  great  caution, 
and,  during  the  extension,  each  piece  gently  slipped 
under  it,  or  the  whole  must  be  passed  under  at  once, 
being  first  rolled  round  the  several  splints,  in  such 
a  manner,  that  the  apparatus  requires  only  to  be 
opened. 

62.  Extension  is  now  made  in  the  mode  already 
pointed  out  (29  and  30),  and  then  the  application  of 
the  apparatus  is  begun,  for  which  the  surgeon  must 
be  situated  on  the  external  side  of  the  fractured  thigh, 
while  an  aid,  placed  on  the  other  side,  gives  him 
assistance. 


247 

1st,  On  the  thigh,  next  to  the  skin,  are  first 
applied  the  long  and  circular  compresses,  accurately- 
spread  out  so  as  to  have  no  wrinkles  in  them,  and 
previously  wet  with  vegeto- mineral  water.  Around 
it  are  then  applied,,  in  succession  and  from  below 
upwards,  each  strip  of  the  bandage  (EE)  moderately 
ti#it. 

2dly,  The  lower  end  of  the  leg  is  now  covered 
with  a  thick  compress,  intended  toprevent  the  im- 
pression of  the  roller  (L),  which  is  fixed  in  such  a 
manner,  that  its  middle  is  first  laid  on  the  tendo  Achil- 
Us,,  a  little  above  the  heel,  while  its  two  ends,  crossing 
each  other  on  the  upper  part  of  the  foot,  are  canied 
on  each  side  to  its  sole,  where  crossiiig  again,  they 
are  then  laid  down  till  the  close  of  the  application  of 
the  apparatus. 

3dly,  Along  the  thigh  are  placed  laterally  two  bol- 
sters, which,  from  their  thickness  being  easily  increas- 
ed or  diminished  in  consequence  of  the  moveable 
nature  of  the  chaff,  mould  themselves  to  the  inequali- 
ties of  the  limb. 

4thly,  Around  the  two  lateral  splints,  the  surgeon 
and  his  assistant  roll,  each  on  his  respective  side,,  the 
two  edges  of  the  junk-cloth,,  so  that  both  splints,  by 
being  accurately  applied  on  the  bolsters,  may  make 
a  uniform  compression  on  the  whole  part. 

5tlily,  The  third  bolster  (dddd)  is  then  appli- 
ed on  the  anterior  part  of  the  limb,  and  over  it  the 
splint  (CC). 

6.  The  bits  of  tape  passed  under  the  apparatus  to 
the  number  of  four  for  the  thigh,  and  three  for  the  leg, 
are  tied  in  succession  on  the  external  splint,  lest  the 
knots,  should  they  correspond  to  the  thigh,,  might,  by 


248 

their  contact,  prove  troublesome.  That  one  next  to 
the  fracture  is  tied  first,  and  they  are  all  drawn  as  tight 
as  the  patient  can  bear  them  without  uneasiness. 

7.  The  body-bandage  is  now  fixed  on  the  pelvis, 
in  such  a  manner,  as  to  secure  laterally  the  external 
splint,  and  is  itself  retained  by  the  sub- femoral  ban- 
dage (H),  that  is,  the  bandage  passing  under  the  thigh. 

8.  A  thick  compress  placed  beneath  the  tubero- 
sity of  the  ischium,  serves  as  a  cushion  or  bolster  to 
protect  the  part  fixDm  the  pressure  of  the  roller  (g  g) 
which,  being  passed  first  under  the  apparatus,  and 
drawn  afterwards  obliquely  from  within  outwards, 
and  from  above  downwards,  takes  its  points  of  bear- 
ing or  action,  in  one  part,  on  the  tuberosity  of  the 
ischium,  and  in  the  other,  on  the  upper  end  of  the  ex- 
ternal splint,  and  is  tied  ip  the  fold  or  hollow  of  tlie 
groin. 

9.  The  two  ends  of  the  bandage  (L)  previously 
made  to  cnoss  each  other  on  the  sole  of  the  foot,  arc 
passed  the  one  through  the  mortise,  and  the  other 
through  the  hollow  or  notch  in  the  lower  end  of  the 
same  splint,  and  then,  being  drawn  forcibly,  are  tied 
in  a  firm  knot,  so  as  to  act  as  a  substitute  for  the  hands 
of  tlie  assistant,  who  now  lets  go  the  patient's  foot. 

10.  If  the  roller  (g  g)  become  relaxed,  it  is  tight- 
ened again,  and  the  patient  being  laid  in  a  suitable 
position,  the  limb  is  protected  from  the  pressure  of 
the  bed  clothes,  by  a  kind  of  basket  placed  over  it. 

11.  A  roller  (K  k)  laid  first  on  the  sole  of  the 
foot,  and  then  brought  across  over  its  upper  side,  and 
fastened  laterally  to  each  splint,  senses  to  secure  tliat 
part  from  turning  outward  or  inward,  and  thus  pre- 
sents the  rotation  of  tiie  limb. 


249 

63.  If  the  mode  of  operation  of  this  bandage  be 
compared  with  the  general  indications  formerly  esta- 
blished (38)  for  all  oblique  fractures  of  the  os  femo- 
ris,  it  will  be  easy  to  perceive  that,  conformably  to 
those  indications,  it  tends,  1st,  to  draw  the  inferior 
fragment  downward ;  2dly,  to  retain  the  superior  one 
up;  3dly,  and  to  prevent  the  rotation  of  the  lower 
fragment,  and  secure  the  immobility  of  the  limb. 

64.  It  is  evident  that  the  bandage  or  roller  (g  g)  so 
unites  the  pelvis  to  the  external  splint  (A A},  that  the 
latter  cannot  be  pushed  upwards,  without  draw  ing  the 
former  in  tlie  same  direction,  as  well  as  the  superior 
fragment  which  adheres  "to  it.  But  if,  after  this  roller  is 
fixed,  the  lower  one  (L)  be  tightened,  the  first  effect 
produced  is,  to  push  the  external  splint  forcibly  up- 
wards ;  the  second,  to  draw  the  leg,  and  with  it  the 
inferior  fragment  downwards ;  so  that,  by  fixing  the 
roller  (L)  in  the  notch  and  mortise  of  the  splint  with 
tht  necessary  degree  of  tightness,  extension  and  coun- 
ter-extension ai'c  made  permanent.  By  this  means 
the  muscles,  being  kept  on  a  stretch,  lose  by  degrees 
their  power  of  contraction,  which  is  still  further  di- 
minished, by  the  immoveable  state  in  which  they  are 
kept,  and  by  the  compression  made  on  them  by  the 
bandage  of  strips.  So  that,  on  the  one  hand,  the  in- 
ferior fragment  will  have  no  tendency  to  rise  upwards, 
and  even  if  it  had,  it  will  meet  with  a  sufficient  resist- 
ance to  prevent  it;  while,  on  the  other  hand,  the 
superior  fi-agment  will  not  be  pushed  downwai'ds  by 
the  pelvis. 

65.  To  this  advantage  is  added  that  of  a  state  of 
perfect  immobility.  The  pelvis,  the  leg,  the  thigh. 


250 

and  the  foot  being  firmly  fixed  on  the  external  splint, 
constitute  one  entire  whole,  all  the  parts  of  which 
must  retain,  with  respect  to  each  other,  the  same  re- 
lative position.  Should  even  a  stroke  be  accidentally- 
given  to  this  assemblage  of  parts  now  converted  into 
a  solid  whole,  each  portion  of  it  will  move  at  the  same 
time,  there  will  be  no  partial  motion,  and  the  relative 
position  of  the  parts  will  not  be  changed.  Hence  the 
advantage  of  being  able  to  raise  the  patient  without 
apprehension;  a  most  desirable  circumstance  indeed, 
in  a  position  so  painfiil  and  so  long  continued  (26). 
The  external  splint,  being  extended  beyond  the  sole 
of  the  foot,  prevents  the  lower  fragment  from  obey- 
ing a  tendency,  which  it  sometimes  has,  to  displace 
itself  by  a  rotation  on  its  axis.  Should  this  tendency 
be  towards  the  internal  side,  an  occurrence  much 
more  rare,  the  lengthening  of  the  internal  splint  will 
effectually  prevent  it. 

67.  These  considerations  induced  Desault  to  re- 
nounce his  ancient  mode  of  making  permanent  ex- 
tension, and  employ  this  exclusively,  in  the  latter 
years  of  his  practice.  Like  all  other  kinds  of  appara- 
tus, formed  principally  of  rollers,  this  is  very  subject 
to  become  relaxed;  and  requires,  therefore,  great 
attention  on  the  part  of  the  surgeon.  It  ought  to  be 
examined  attentively  every  day,  particulai'ly  the  two 
extending  bandages  (L  and  g  g).  As  soon  as  they  be- 
come relaxed,  they  must  be  immediately  tightened 
again :  without  this  precaution,  the  effect  of  the  ap- 
paratus will  be  lost.  Be  vigilant  also,  with  respect  to 
the  compress  placed  between  the  roller  (g  g)  and  the 
tuberosity  of  the  ischium.  Should  this  slip,  the  roller 


251 

being  frequently  tightened,  and  pressing  immediately 
on  the  skin,  may  produce  excoriations  and  ulcers 
difficult  to  be  healed,  particularly  in  females.  The 
roller  itself  may  slip,  and  then,  having  no  longer  a 
solid  point  of  support  and  action  on  the  tuberosity  of 
the  ischium,  it  makes  extension  in  but  an  imperfect 
manner. 

67.  One  of  the  charges  brought  against  this  ap- 
paratus is,  the  facility  with  which  the  upper  roller  be- 
comes displaced,  a  facility  that  imposes  a  degree  of 
care  and  attention,  of  which  few  surgeons  are  capable, 
and  which,  when  bestowed  even  by  Desault  himself, 
did  not  always  prevent  the  shortening  of  the  limb. 

68.  Further,  the  extension  made  on  the  fold  of 
the  thigh,  partakes,  a  little,  of  the  inconvenience  that 
accompanied  the  ancient  mode  of  reduction,  namely, 
that  of  compressing  and  irritating  the  muscles  of  the 
upper  and  internal  pait  of  the  thigh  (30).  This  incon- 
venience would  be  still  more  sensible,  if,  for  want  of 
extending  to  a  sufficient  distance  up  the  pelvis,  the 
upper  splint  should  allow  the  roller  to  cross  the  mus- 
cles at  an  angle  somewhat  acute,  as  it  would  then 
enclose  and  press  on  the  greater  part  of  them. 

69.  If  some  unfavourable  cases,  resulting  without 
doubt  from  these  inconveniences,  did  occur  in  the 
practice  of  Desault,  a  multitude  of  successful  ones 
still  attest  the  advantages  of  this  method;  and  there 
is  not  a  pupil  who  attended  any  time  at  the  Hotel- 
Dieu,  without  witnessing  them.  I  will  relate  but  one 
case,  collected  by  Chorin,  to  furnish  a  detail  of  the 
treatment  subsequent  to  reduction,  referring  the  rea- 
der for  further  information  to  the  Journal  of  Surgery. 


252 

Case  II.  Theresa  Little- John,  aged  45  yearSj 
fell,  drawn  by  the  weight  of  her  own  body,  through 
a  window  in  a  balcon}^,  from  which  she  was  leaning. 
She  was  instantly  taken  up,  carried  to  her  own  house, 
and  from  thence  to  the  Hotel-Dieuy  which  she  enter- 
ed on  the  28th  of  October,  1790.  From  the  signs 
mentioned  (9),  a  fracture  was  discovered  towards  the 
lower  part  of  the  thigh;  its  oblique  disposition  re- 
quired an  apparatus  to  make  permanent  extension. 
This  was  applied  in  the  usual  manner,  and,  in  an  in- 
stant, the  patient,  who  had  experienced,  since  her 
fall,  severe  pain,  became  calm,  and  was  completely 
relieved. 

In  the  night,  pains  returned;  agitation;  some 
spasmodic  motions;  an  anodyne  draught  adminis- 
tered in  the  morning.  In  the  course  of  the  day,  these 
troublesome  symptoms  disappear;  a  slight  swelling 
at  the  ancle.  Third  day,  no  pain;  swelling  gone; 
aliment  increased.  Sixth  day,  patient  permitted  to 
return  to  her  usual  regimen;  extending  rollers  re- 
laxed ;  lower  one  tightened :  eleventh  day,  apparatus 
renewed;  fragments  in  perfect  contact:  thirteenth 
day,  limb  moved  incautiously ;  a  slight  shortening ; 
apparatus  reapplied ;  extending  bandages  drawn 
tight :  sixteenth  day,  a  disposition  slightly  bilious ; 
evacuants  administered  -wdth  success :  twenty-fourth 
day,  a  third  application  of  the  bandage:  thirtieth  day, 
progress  in  consolidation  already  very  evident;  the 
limb  straight:  fortieth  day,  extending  rollers  laid 
aside :  fifty- second  day,  consolidation  complete  with- 
out the  least  deformity. 


2B3 

70.  Tlie  muscular  force,  in  children,  being  weak, 
and  the  weight  of  the  body  inconsiderable,  have,  in 
general,  much  less  influence  in  producing  a  displace- 
ment in  them  than  they  do  in  adults.  Wheli,  there- 
fore, fractures  occur  in  subjects  under  six  or  seven 
years  old,  the  resistance,  on  the  part  of  the  apparatus, 
need  not  be  so  great.  In  general  the  lateral  pressure 
which  it  makes,  and  the  bearing  of  its  different  pieces 
against  the  limb,  are  sufficient  to  prevent  the  return 
of  deformity,  when  this  has  been  perfectly  removed 
by  reduction. 

71.  In  such  cases  Desault  covered  the  thigh  with 
a  circular  bandage,  made  of  a  roller  seven  ells  long, 
and  three  inches  broad.  Beginning  with  this  below^ 
near  to  the  condyls,  he  carried  it  upwards,  by  oblique 
and  reversed  turns,  to  the  pelvis,  round  which  he 
threw  a  cast;  then,  giving  the  ball  into  the  hand  of 
an  assistant,  he  applied  four  splints,  one  before,  ano- 
ther behind,  and  one  on  each  side :  directing  these  to 
be  held  at  their  lower  part  near  to  the  knee,  he  resu- 
med the  roller,  and  secured  them  firmly  b}^  a  second 
series  of  circular  and  reversed  turns,  descending  to 
the  lower  extremity  of  the  thigh.  The  limb  was  then 
placed  in  a  proper  position,  and,  in  general,  of  what- 
ever kind  the  fracture  was,  whether  oblique  or  trans- 
verse, this  simple  bandage,  without  the  aid  of  perma- 
nent extension,  was  sufficient  to  retain  it. 

72.  It  would  be  difficult  to  determine  the  period 
necessary  for  the  consolidation  of  fractures  of  the  os 
femoris.  Numerous  circumstances  concur  to  influ- 
ence this  work  of  nature,  which  is,  in  general,  ex- 
tended beyond  the  term  of   f^prty  days,   vulgarly 


254 

assigned  to  it  by  the  people  at  large.  Besides,  a 
stiffness  of  the  limb,  the  inevitable  effect  of  its  long 
state  of  rest,  still  adds  to  the  length  of  the  patient's 
confinement,  by  retarding  the  necessary  motions,  the 
return  of  which,  as  in  other  similar  cases,  can  be  ac- 
celerated only  by  exercise. 

73.  Complicated  fi^actures  of  the  os  femoris, 
being  included  in  the  general  class  of  solutions  of 
continuity  of  that  description,  cannot  be  at  present 
particulai'ly  considered.  We  will  only  remark,  that 
here,  in  like  manner,  as  in  fractures  of  the  clavicle, 
permanent  extension  constitutes  the  most  effectual 
method  of  preventing  the  pains,  oftentimes  insup- 
portable, occasioned  by  splinters  or  points  of  bone 
irritating  the  soft  parts,  from  being  pressed  against 
them  by  muscular  action  in  its  tendency  to  shortea 
the  limb. 

§  IX. 

OF  PERMANENT  EXTENSION  IN  OLD  ERACTURES. 

74.  I  will  close  this  article  by  a  few  remarks  on 
the  advantages  of  peririanent  extension  in  old  frac- 
tures. Nature  reunites  fractures  differently,  accord- 
ing to  the  relation  of  the  divided  surfaces  to  each 
other.  Are  those  surfaces  in  perfect  contact?  If  so, 
they  are  chiefly  instrumental  in  the  formation  of 
callus,  which  then  probably  acts  in  a  manner  similar 
to  the  reunion  of  wounds.  On  the  other  hand,  does 
an  overlapping  of  the  fragments  separate  the  divi- 
ded surfaces  from  each  other;  the  reunion  takes 
place  then  principally  on  the  sides,  by  a  kind  of 


255 

enlargement  of  the  bones,  produced  no  doubt  by  the 
periosteum.  Such  is  the  mode  of  consolidation, 
which,  on  opening  dead  bodies,  is  found  in  most 
obhque  fractures  of  the  os  femoris,  succeeded  by  a 
shortenmg  of  the  Hmb. 

75.  Hence  it  follows,  that  this  shortening,  which 
would  readily  yield  to  extension,  at  the  time  of  the 
fracture,  becomes  obstinate  in  its  resistance,  in  pro- 
portion to  the  age  of  the  accident.  In  such  a  case, 
indeed,  the  substances  destined  to  reunite  the  over- 
lapping fi'agments,  acquiring  daily  more  and  more 
solidity,  oppose  to  the  reduction  obstacles  constantly 
increasing.  Hence,  most  practitioners  regai'd  this 
reduction  as  beyond  the  resources  of  art,  after  the 
expiration  of  the  twelfth  or  fifteenth  day.  Nor  is  this 
opinion  entertained  without  some  foundation,  for  at  a 
later  period,  almost  all  efforts  at  reduction,  however 
powerful,  have  proved  unavailing.  But  that  which 
cannot  be  performed  by  a  very  powerful  effort,  acting 
momentarily,  is,  notwithstanding,  oftentimes  easily 
attainable  by  a  much  weaker  one,  provided  it  be  long 
continued.  The  following  cases  are  in  proof  of  this. 

Case  HI.  Ann  Gallot,  of  Melun,  aged  sixty- 
nine,  having  fractured  her  right  thigh,  by  falling 
down  the  steps  of  a  cellar,  remained  twenty-two  days 
without  assistance,  and  without  even  knowing^  the 
nature  of  the  accident,  when,  on  consulting  a  sur- 
geon, she  was  sent  to  the  hospital  at  Versailles. 
From  the  long  standing  of  the  disease,  a  reduction 
being  despaired  of,  and  no  one  being  willing  even  to 
undertake  it,  the  patient  was  sent  to  the  Hotel- Dieu, 
on  tlie  27th  of  Februaiy,  1791. 


QK 


^O 


A  shortening  of  four  inches  distinguished  the 
diseased  thigh  from  the  sound  one.  The  overlap, 
ping  was  sensible  to  the  touch :  in  the  mean  time, 
a  slight  mobility  at  the  place  of  fracture,  inspired 
a  hope  of  being  able,  if  not  to  restore  to  the  limb  its 
natural  form,  at  least  to  diminish  the  contraction. 
Several  efforts  were  made  at  first,  but  without  suc- 
cess, as  Desault  foresaw.  The  appai^atus  for  perma- 
nent extension  was  applied:  on  the  day  following, 
the  extending  rollers  being  a  little  relaxed,  were 
regain  tightened.  Fourth  day,  a  sensible  increase  in 
the  length  of  the  limb;  apparatus  renewed.  Ninth 
day,  the  left  thigh  but  an  inch  longer  than  the  other : 
eleventh  day,  equahty  in  length  almost  re-established. 
After  this,  the  apparatus  was  kept  constantly  applied 
and  renewed  from  time  to  time. 

Fortieth  day,  consolidation  already  perceptible : 
forty-sixth  day,  symptoms  of  a  putrid  fever  have 
m.ade  tlieir  appeai'ance :  fiftieth  day,  symptoms  worse; 
fifty-second,  something  better:  fiifty-fifth,  Avorse 
again:  fifty-seventh,  dead.  On  opening  the  body, 
an  oblique  fracture  vvas  found,  its  surfaces  very 
nearly  in  apposition,  and  already  united  by  a  veiy 
solid  callus. 

Case  IV.  Joseph  Maugrin,  a  saddler,  broke  his 
thigh  in  the  month  of  July,  1793.  A  surgeon  being 
called  to  him,  placed  his  limb  in  an  old  form  of  ap- 
pai'atus,  which  did  not  prevent  a  shortening,  to  the 
the  extent  of  an  inch  and  a  half,  from  showing  itself 
on  the  following  day :  hence  a  new  reduction,  and 
a  new  application  of  the  apparatus :  but  soon  after- 
wards, another   shortening;    the    same    means    to 


257 

remove  it;  the  same  failure  of  means.  Weary  of 
such  trials,  the  surgeon  abandoned  the  limb  to  its 
fate,  contenting  himself  with  merely  keeping  it  in 
the  apparatus. 

On  the  twenty -ninth  day,  Desault  being  called 
in  consultation,  and  finding  the  thigh  shorter  by  three 
inches  than  that  on  the  opposite  side,  proposed  per- 
manent extension,  persuaded  that  this  expedient 
alone  would  soon  be  sufficient  to  re-establish  the 
contact  of  the  fragments.  The  proposal  was  acceded 
to.  On  the  day  following,  the  effects  were  already 
perceptible;  the  thigh  was  lengthened  by  almost  an 
inch.  By  the  sixth  day,  it  was  equal  in  length  to  the 
other :  during  this  period,  the  extending  rollers  were 
tightened  twice  a  day. 

At  the  end  of  two  months  the  consolidation  was 
complete,  and  the  patient  walked  perfectly  well,  ex- 
cept that  there  was  a  little  shortening  of  the  limb, 
trifling  though  indeed,  compared  to  wliat  would  have 
been  the  consequence,  had  the  original  treatment 
been  continued. 

76.  The  lengtliening  of  the  limb,  in  these  cases, 
was  evidently  owing  to  the  continued  action  of  the 
apparatus,  which  effected,  in  a  length  of  time,  what 
the  momentary  eflPorts  of  the  surgeon  could  not  ac- 
complish. This  it  did,  by  destroying  or  gradually 
lengthening  the  medium  of  union,  which  already 
connected  the  overlapping  fragments,  by  that  means 
bringing  their  separated  surfaces  or  ends  into  contact, 
and  almost  restoring  to  the  bone  its  primitive  form. 

Art  cannot  always,  with  certainty,  command  such 
success,  and  perhaps,  even  at  a  less  advanced  period, 

34 


258 

a  more  rapid  progress  of  reunion  might  leave  but  lit- 
tle ground  for  hope.  But,  could  only  an  inch  in  length 
be  gained  by  permanent  extension,  would  it  not  be 
proper  to  have  recourse  to  it,  particularly  as  no  in- 
convenience can  result  from  the  trial?  To  prevent 
deformity  altogether,  is  the  first  object  of  art ; 
but  when  that  c^inot  be  attained,  to  lessen  it  is  the 
second. 

FRACTURES  OF  THE  UPPER  END  OF 
THE  OS  FEMORIS. 

The  history  of  fractures  of  the  upper  end  of  the 
OS  femoris,  includes,  1st,  Those  of  the  great  trochan- 
ter: 2dly,  Those  of  the  neck.  These  fractures, 
sometimes  existing  together,  and  at  other  times 
separately,  are  very  different  with  regard  to  the  fre- 
quency of  their  occurrence:  the  one  taking  place 
very  rarely,  has  but  slightly  engaged  the  attention  of 
practitioners,  who  have  multiplied  their  researches 
with  regard  to  the  other,  particularly  in  late  years, 

FRACTURES  OF  THE  GREAT  TRO- 
CHANTER. 

OF   tH£  VARIETIES  AND  CAUSES. 

17,  Fractures  of  the  great  trochanter  are  the  effect 
either  of  falls  on  that  protuberance,  or  of  the  action 
of  bodies  striking  against  it.  Oblique  or  transverse, 
situated  sometimes  at  its  summit,  and  sometimes  at 


■''m^ 


259 

its  base,  these  fractures  may  be  either  simple  or 
complicated.  They  are  rendered  complicated  some- 
times by  splinters  and  a  swelling,  as  happens  when  a 
ball  produces  the  division,  and  at  other  times  by  a 
fractiu'e  of  the  neck  of  the  bone,  an  example  of  which 
we  find  in  the  Journal  of  Surgery,  in  the  case  of  a 
man  seventy  years  of  age,  who  had  been  long  subject 
to  the  itch. 

78.  Whatever  the  varieties  may  be,  the  fracture 
will  be  characterized,  1st,  By  a  facility  of  moving 
the  great  trochanter  in  every  direction,  while  the  pel- 
vis and  the  thigh  remain  without  motion :  2dly,  By 
a  crepitation,  arising  from  the  friction  of  the  divided 
surfaces  against  each  other:  3dly,  By  there  being  no 
shortening  of  the  limb,  when  the  fracture  exists  alone : 
4thly,  By  the  fragments  being  brought  together  in 
abduction,  and  separated  in  adduction:  5thly,  By 
the  position  of  the  great  trochanter  being  higher  and 
more  anterior  than  natural.  The  presence  of  these 
signs  is  the  more  readily  perceived,  because,  being 
superficially  situated,  this  protuberance  can  be  easily 
felt,  and  yields  to  the  motions  impressed  on  it. 

§XI. 

OF  THE   REDUCTION,  AND   THE  MEANS  OF  RE- 
TAINING  IT. 

79.  The  reduction  is  effected,  by  pushing  the 
separated  fragment  in  the  direction  opposite  to  that 
of  its  displacement,  by  bringing  it  to  its  natural  level, 
and,  in  certain  cases,  by  moving  the  thigh  a  little 
outwai'ds;   it  is  retained  bv  means  of  some  com- 


260 

presses  placed  by  its  sides,  and  secured  by  a  roller 
directed  obliquely  from  the  sound  hip  towards  that 
part,  of  the  thigh  corresponding  to  the  fracture,  and 
representing  a  true  spica  bandage. 

80.  A  fracture  produced  by  a  gun-shot  wound, 
always  renders  large  incisions  necessaiy,  for  the  pur- 
pose of  extracting  foreign  bodies,  and  relaxing  the 
aponeurosis  of  the  fascia  lata,  which  suffers  too  great 
a  degree  of  tension  in  this  place,  and  might,  if  not 
dilated,  produce  a  very  troublesome  stricture.  A 
fracture  complicated  by  splinters,  but  without  an  ex- 
ternal wound,  and  produced  by  a  body  striking  against 
the  part,  seldom  requires  any  particular  apparatus, 
because,  adhering  as  yet  to  the  periosteum,  the  se- 
parated portions  of  the  os  femoris  may  unite  again, 
either  among  themselves,  or  with  the  fragments. 

FRACTURES  OF  THE  NECK  OF  THE  OS 
FEMORIS. 

§xn. 

OF   THE    CAUSES. 

81.  The  neck  of  the  os  femoris,  being  surround- 
ed by  a  large  mass  of  soft  parts,  and  protected  by  the 
great  trochanter,  which  forms  its  external  boundary, 
is  almost  completely  secured  from  the  immxcdiate  ac- 
tion of  external  bodies,  and  consequently  from  direct 
fractures.  Whenever  it  sustains  a  fracture,  it  is  al- 
ways by  a  true  counter- stroke,  resulting'  from  a  fall, 
sometimes  on  the  great  trochanter,  and  at  other  times 


261 

on  the  sole  of  the  foot  or  the  knee.  But  fractures 
produced  in  the  first  mode,  are  much  more  frequently 
met  with  in  practice,  than  those  produced  in  the  se-. 
cond,  doubtless  because,  in  the  latter,  the  motion  is 
weakened  by  the  extent  of  parts  through  which  it  is 
distributed,  previously  to  its  amval  at .  the  neck  of 
the  OS  femoris.  Out  of  thirty  observations  made  by 
Desault,  on  fractures  of  this  description,  twenty-four 
of  them  were  produced  by  falls  on  the  side.  All  those 
recorded  by  Sabatier,  in  his  interesting  memoir,  ap- 
pear to  have  been  produced  by  similar  falls. 

§  XIII. 

OF    THE    VARIETIES. 

82.  Fractures  of  the  neck  of  the  os  femoris  may 
occur,  1st,  in  the  middle  part  of  it,  where  it  is  small- 
est, and  where  nature  has  not  thrown  together,  as  she 
does  irl  the  middle  of  the  long  bones  so  often  exposed 
to  fractures,  a  great  quantity  of  compact  substance : 
2dly,  at  its  upper  end,  where  it  is  united  to  the  head 
of  the  bone :  3dly,  at  its  junction  with  the  great  tro- 
chanter, where  the  solution  of  continuity  may  be  out- 
side of  the  joint,  a  circumstance  which  doubtless 
happens  much  more  frequently  than  has  been  hitherto 
suspected. 

83.  The  division,  rarely  oblique,  is  almost  always, 
transverse :  sometimes,  in  the  latter  case,  the  neck 
remains  enclosed  or  imbedded,  as  it  were,  in  the  body 
of  the  bone,  being  fractured  in  such  a  way,  as  to  pre- 
sent a  hollow  or  notch  of  greater  or  less  depth.  Seve- 
ral cases  of  this  kind  occurred  to  Desault;  one  of 


^62 

them,  modelled  in  wax,  is  deposited  in  the  collection 
of  the  School  of  Health,  and  the  original  preparation 
is  in  my  possession.  The  fi-acture,  though  frequently 
simple,  is  sometim.es  complicated  with  that  of  the 
great  trochanter. 

Case  V.  A  man  having  received  a  kick  from  a 
horse,  on  the  external  and  upper  part  of  the  left  thigh, 
fell  down,  and,  not  being  able  to  move,  was  carried 
home.  Desault  being  called  to  him,  discovered,  1st, 
that  the  great  trochanter,  separated  from  the  bone, 
yielded  readily  to  every  impression  it  received :  2dly, 
tliat  the  limb  was  perceptibly  shortened;  that  the 
least  effort  was  sufficient  to  restore  to  it  its  natural 
length;  and,  that  the  foot  was  turned  outwards,  all 
which  are  characteristic  signs  of  a  fracture  of  the  neck. 

^  XIV. 

OF   THE   SIGNS. 

€4.  Whatever  may  be  the  mode  and  place  of  the 
fracture,  its  diagnosis  presents  difficulties  which  ex- 
perience and  habit  may  doubtless  overcome,  but 
which  t(;>o  frequently  puzzle  and  embarrass  the  most 
enlightened  practitioner.  Let  us  endeavour  to  dimi- 
nish them  somewhat,  by  tracing,  in  their  order  of 
succession,  the  symptoms  which  characterize  the 
accident. 

85.  At  the  time  of  the  fall,  a  sharp  pain  is  felt; 
sometimes  a  report  is  plainly  heard ;  a  sudden  inabili- 
ty to  move  the  limb  occurs;  the  patient  cannot  rise, 
a  circumstance,  however,  which  does  not  always  take 
place.  A  case  is  recorded  in  the  fourth  volume  of  the 


263 

Memoirs  of  the  Academy  of  Surgery,  where  the  pa- 
tient walked  home  after  the  fall,  and  even  rose  up  on 
the  following  day.  Some  examples  of  a  similar  na- 
ture fell  under  the  notice  of  Desault,  one  of  which  he 
has  recorded.  The  interlocking  of  the  two  fragments 
formerly  mentioned  (83),  may  serve  to  explain  this 
fact,  which  is,  however,  in  general,  very  rare. 

86.  A  shortening  almost  always  occurs  in  the 
broken  limb,  but  this  is  more  or  less  perceptible, 
according  as  the  extremity  of  the  fragments  is  retain- 
ed by  the  capsule,  or  as,  the  division  being  without 
die  cavity,  no  resistance  is  made  to  their  displacement. 
The  muscular  action,  di'awing  the  lower  fragment 
upwards,  and  the  weight  of  the  trunk,  pushing  the 
pelvis  and  th6  superior  fragment  downwards,  furnish 
here,  as  in  fractures  of  the  body  of  the  bone,  the  two- 
fold cause  of  this  shortening.  I  will  not  repeat  what 
has  been  already  said  on  this  subject  (10...  14);  I  will 
only  observe,  that,  in  the  present  case,  the  influence 
of  the  muscles  is  even  more  considerable,  because^ 
the  lower  fragment  being  much  longer,  is  of  course 
attached  to  a  greater  mass  of  muscular  fibres.  A 
slight  effort  is  sufficient,  in  general,  to  remove  this 
shortening,  which,  however,  soon  returns,  when  the 
effort  ceases.  This  circumstance  Goursault  and  Sa- 
batier  have  observed,  not  to  occur  in  certain  cases, 
till  some  time  after  the  accident.  A  tumefaction  ap- 
pears in  the  anterior  and  upper  part  of  the  thigh, 
almost  always  proportioned  to  its  shortening,  of  which 
it  appears  to  be  the  effect. 

87.  The  projection  of  the  great  trochanter  is  al- 
most entirely  removed.    That  protuberance,  being. 


264 

directed  upward  and  backward,  is  approximated  to 
the  spine  of  the  ilium.  But  if  it  be  pushed  in  the  op- 
posite direction,  it  readily  yields,  and  then,  returning 
to  its  proper  level,  allows  the  patient  to  move  the 
thigh. 

88.  The  knee  is  a  little  bent.  A  severe  pain 
always  accompanies  the  motions  of  abduction,  when 
they  are  communicated  to  the  limb.  If,  while  the 
hand  is  applied  to  the  great  trochanter,  the  limb  be 
made  to  rotate  on  its  axis,  this  bony  protuberance 
is  perceived  to  turn  on  itself  as  on  a  pivot,  instead 
of  describing,  as  it  does  in  its  natural  state,  the  arch 
of  a  circle,  of  which  the  neck  of  the  os  femoris  is  the 
radius.  This  sign,  which  was  first  observed  by 
Desault,  is  very  perceptible,  when  the  fracture  is  at 
the  root  of  the  neck,  less,  when  it  is  in  the  middle, 
and  very  little,  when  it  exists  tQwards  the  head  of  the 
bone ;  these  are  circumstances,  the  cause  of  which  it 
is  unnecessaiy  to  unfold.  In  rotatory  motions,  the 
lower  fragment,  rubbing  against  the  upper  one,  pro- 
duces a  distinct  crepitation,  a  phenomenon  which 
does  not  however  always  occur. 

89.  The  point  of  the  foot  is  usually  turned  out- 
wards; a  position  which  Sabatier,  Bruninghausen, 
and  most  other  practitioners  regard  as  a  necessary 
effect  of  the  fracture,  although  Ambrose  Pare  and 
Petit  have  borne  witness  that  it  does  not  always 
exist.  Two  cases,  reported  on  this  subject  by  cele- 
brated surgeons,  have  been  thought  unfounded  by 
Louis,  who  has  attributed  them  either  to  an  error  in 
language,  or  a  mistake  of  the  transcriber.  But  the 
practice  of  Desault  has  fully  confirmed  their  possibi- 


265 

lity.  The  first  patient  whom  he  had  under  his  cai^e, 
at  the  hospital  of  Charity,  after  he  was  appointed 
surgeon  in  chief,  laboured  under  a  fi^acture  which 
presented  this  phenomenon.  Many  other  examples 
occurred  to  him  afterwards,  and  he  believed  it  might 
be  laid  down  as  an  established  principle,  that,  in 
fractures  of  the  neck  of  the  os  femoris,  the  direction 
of  the  foot  outwards  is  to  that  inwards  as  8  to  2. 

90.  The  common  opinion  is,  that  this  direction 
outwards  is  to  be  attributed  to  the  muscles  that 
perform  rotation.  But,  were  that  the  case,  1st,  it  is 
evident  that  it  would  always  exist:  2dly,  all  the 
muscles  running  from  the  pelvis  towards  the  trochan- 
ter, except  the  quadi'atus,  ai-e  in  a  state  of  relaxation, 
in  consequence  of  the  approximation  of  the  os  femo- 
ris to  their  points  of  insertion :  3dly,  muscles  in  a 
state  of  contraction  would  not  allow  the  point  of  the 
foot  to  be  drawn  so  easily  inwards.  Is  it  not  more 
probable,  that  the  weight  of  the  part  draws  it  in  the 
direction  in  which  it  is  usually  found. 

91.  From  the  foregoing  considerations,  it  follows, 
that  none  of  the  signs  of  a  fracture  of  the  neck  of 
the  OS  femoris,  is  exclusively  characteristic,  that  the 
whole  of  them,  taken  separately,  would  be  insuffi- 
cient, and  that  it  is  their  assemblage  alone  which  can 
throw  on  the  diagnosis  that  light  which  is  oftentimes 
w^anting  to  it,  even  in  the  view  of  able  practitioners. 
But  after  all,  in  the  present  case,  as  in  every  other 
one,  should  any  doubt  exist,  it  is  right  to  take  the 
safe  side,  and  apply  the  apparatus,  which  is  indeed 
useless  but  not  dangerous  if  the  disease  does  not 

exist,  but  indispensably  necessary  if  it  does. 

35 


266 

OP    THE   PROGNOSIS. 

92.  The  existence  of  a  fracture  being  ascertained, 
what  prognosis  is  to  be  formed  respecting  it?  In  an- 
swer to  this  general  question,  it  will  be  sufficient,  I 
think,  to  resolve  the  following  paiticular  ones.  What 
accidents  accompany  the  fracture  in  the  first  instance? 
What  phenomena  make  their  appearance  during  its 
reunion?  In  what  manner  does  it  affect  the  patient, 
as  to  his  power  of  Avalking,  after  reunion  has  taken 
place. 

93.  If  we  attend  to  the  opinion  of  authors,  on 
this  fracture,  we  will  find  that  they  represent  it  in 
very  dismal  colours,  as  if  it  were  necessarily  produc- 
tive of  the  most  serious  effects.  Inflammation  of 
the  parts  adjacent  to  the  neck  of  the  os  femoris,  nu- 
merous and  repeated  abscesses  arising  from  this 
inflammation,  propagating  themselves  externally  and 
communicating  with  the  interior  of  the  joint,  gan- 
grene itself,  as  Morgagni  remarks  in  a  particular 
case,  convulsions  of  the  limb,  an  cedema  occurring 
in  it,  and  a  slow  fever  destroying  the  patient  by  de- 
grees ;  such  is  the  dismal  catalogue  of  misfortunes, 
generally  considered  as  necessarily  attendant  on  the 
kind  of  fracture  under  consideration.  Bruninghausen 
remonstrated  against  this  fatal  prognosis  of  authors, 
and  Siebold,  one  of  the  most  celebrated  German 
practitioners,  among  a  great  number  of  cases  that 
fell  under  his  care,  had  no  such  accidents  to  en- 
counter.   Desault  never  experienced  them.    Doubt- 


267 

less  they  are  prevented  by  our  more  exact  and  more 
skilful  modes  of  treatment.  It  is  thus  that  under  a 
more  judicious  treatment,  fractures  of  the  olecranon 
and  of  the  rotuia,  are  no  longer  marked  with  those 
terrible  consequences  formerly  attributed  to  them. 

94.  In  as  much  as  the  organization  of  the  os  fe- 
moris,  is  nearly  the  same  in  its  neck  and  in  its  body, 
it  is  difficult  to  conceive  how  the  progress  of  nature 
can  be  diflPerent  in  fractures  of  these  two  parts ;  why 
the  first,  in  being  denied  the  power  of  healing  or 
reunion  should  be,  in  this  respect,  distinguished  from 
all  other  living  parts  of  animals,  which  ai'e  particularly 
characterized  by  that  power,  when  they  have  sustain- 
ed a  solution  of  continuity.  Many  practitioners,  even 
at  the  present  day,  advocate  this  doctrine,  which  is 
built,  one  while,  on  the  circumstance  of  the  perios- 
teum not  being  continued  along  the  neck  of  the  os 
femoris;  another  while,  on  a  belief  that  the  head  of 
this  bone  cannot  receive  a  sufficiency  of  nourishment 
for  the  work  of  consolidation,  in  consequence  of  being 
attached  to  the  rest  of  the  system,  only  by  the  round 
ligament,  and  again,  on  an  opinion,  that  the  synovial 
fluid,  by  wetting  tlie  divided  surfaces,  prevents  their 
reunion. 

95.  But  is  the  periosteum  the  only  agent  in  the 
formation  of  callus?  Modem  experience  has  refuted 
this  opinion,  which,  like  many  others,  will  therefore 
in  a  short  time  exist  only  in  the  history  of  our  errors. 
Were  it  even  true  that  the  periosteum  is  here  indis- 
pensably necessary,  is  not  its  place  supplied  by  the 
fold  of  the  capsule,  which  suiTounds  both  the  head 
and  neck  of  the  os  femoris?  Besides,  why  cannot 


268 

callus  be  formed  by  that  part  which  has  had  sufficient 
power  to  accomplish  ossification,  since  it  is  univer- 
sally acknowledged,  that,  in  these  two  processes,  the 
labour  of  nature  is  nearly  the  same. 

96.  The  head  of  the  bone,  separated  from  the 
soft  parts,  and  attached  to  the  acetabulum  by  the 
round  ligament,  always  receives  through  that  liga- 
ment a  sufficiency  of  nutriment  to  enable  it  to  live  in 
that  cavity ;  for,  there  is  no  instance  of  its  having  suf- 
fered mortification  in  consequence  of  a  fi-acture. 
Why,  then,  should  it  not  partake  of  the  properties  of 
life,  and  particularly  of  the  faculty  of  reunion  when 
placed  in  regular  apposition  with  the  body  of  the 
bone? 

97.  What  shall  we  say  respecting  the  idea  of  the 
synovia  wetting  the  divided  surfaces,  and  by  that 
means  preventing  their  reunion?  The  history  of  frac- 
tures communicating  with  joints,  better  known  at  the 
present  day,  answers  this  objection,  which  is  indeed 
nothing  but  the  offspring  of  mere  hypothesis.  To 
these  considerations,  which  are  dictated  by  reason, 
and  to  which  many  more  might  be  added,  let  us  unite 
the  proofs  derived  from  experience,  and  we  will  find 
numerous  examples  of  cures  actually  performed,  par- 
ticularly in  latter  times;  the  truth  of  this  is  attested 
by  many  cases  collected  by  Desault,  both  at  the  hos- 
pital of  Charity  and  the  Hotel-Dieu.  Bruningaushen 
and  Sieboid,  have  had  equal  success.  Many  analo- 
gous facts  have  been  presented  to  the  Academy  of 
Surgery.  In  the  cabinet  of  the  School  of  Health,  are 
deposited  some  preparations  obtained  from  the  cabi- 
net of  Desault,  calculated  to  remove  all  difficulties  and 
doubts  from  this  subject. 


269 

98.  Wc  must  acknowledge,  however,  that  in  per- 
sons advanced  in  years,  the  cure  is  always  difficult, 
often  very  tedious,  and  sometimes  impracticable, 
however  carefully  the  treatment  may  be  conducted. 
But  this  'is  only  a  necessary  consequence  of  the  laws 
of  ossification,  which,  constantly  accumulating  in  the 
bones  too  great  a  quantity  of  calcareous  matter, 
seems  to  deprive  them  by  degrees  both  of  life  and  all 
its  properties.  Yet  Lesne  laid  before  the  academy  a 
case  of  reunion  obtained  in  a  subject  at  the  advanced 
age  of  eighty-four. 

99.  The  observations  of  some  modem  practi- 
tioners seem  to  prove,  that  the  reunion  here  is  not 
produced  by  a  substance  similar  to  common  callus, 
but  by  a  kind  of  ligamento- cartilaginous  tissue,  in 
like  manner  as  in  the  rotula,  and  the  olecranon.  But 
why  need  we  inquire  after  the  means  employed  by 
nature?  those  of  art  must  be  the  same.  It  will  be 
always  necessary  to  favour  the  reunion,  by  bringing 
the  fragments  into  contact,  and  maintaining  them  so. 
Without  this  contact,  either  a  cure  will  never  be  ob- 
tained, or  the  substance  destined  to  effect  a  reunion, 
becoming  deformed  and  too  bulky,  wall  impede  mo- 
tion. 

100.  Lameness  has  been  long  considered  as  the 
inevitable  consequence  of  fractures  of  the  neck  of  the 
OS  femoris.  Ludwig,  professor  of  surgery  at  Leipsick, 
has  particularly  advocated  this  opinion,  which  is 
supported  by  Sabatier,  and  Louis,  who  considered 
the  total  destruction  of  the  neck  of  the  bone,  as  the 
cause  of  the  lameness.  But  few  such  examples  are  to 
be  found  on  record.  Ruisk  has  p'iven  an  enffravins^  of 


270 

one.  Lameness  v/hen  it  does  take  place,  depends,  as 
it  does  in  oblique  fractures  of  the  body  of  the  bone, 
on  the  overlapping  of  the  fragments,  to  "vvhich  no 
opposition  has  been  made;  so  that  the  insufficiency 
of  our  means,  and  not  the  nature  of  the  disease,  gives 
rise  to  tliis  accident,  v/hich  Desault  seldom  expe- 
rienced in  his  practice. 

101.  Fromx  what  has  been  said,  it  appeal's,  that, 
in  all  respects,  authors  have  given  a  much  more  un- 
favourable prognosis  in  fractures  of  the  neck  of  the 
OS  femoris  than  facts  and  the  nature  of  the  affection 
will  justify,  that  the  progress  of  these  fractures  is 
the  same  with  that  of  all  others,  and  that,  when  treat- 
ed with  equal  skill,  there  is  no  reason  why  their 
termination  should  not  be  equally  favourable. 

§.XVI. 

OF   THE   REDUCTION   AND   THE   MEANS   OF   MAIN- 
TAINING   IT. 

102.  Reduction,  in  this  case,  is  attended  in 
general  with  but  little  diflicult3\  The  patient,  lying 
on  his  back,  is  held  under  the  arm-pits,  and  by  the 
upper  part  of  the  pelvis,  by  assistants  who  make 
counter- extension  in  this  "^v^ay,  without  being  obliged 
to  pass,  as  recommended  by  the  Academy  of  Sur- 
gerv,  a  strap  under  the  affected  thigh  (30).  Another 
assistant  makes  extension,  according  to  the  method 
formerly  described  (29),  drawing  the  point  of  the 
fragment  very  gradually  in  the  direction  opposite  to 
that  which  it  has  taken  in  becoming  displaced,  and 
making  the  thigh  at  the  same  time  rotate  a  little  on 


271 

its  o^vn  axis.    This  gentle  rotation  renders  success 
more  certain. 

103.  If  things  be  properly  arranged,  a  slight  effort 
is  sufficient  to  bring  the  separated  fi-agments  into 
contact  and  to  restore  to  the  limb  its  natural  form ; 
for,  as  I  have  already  observed  (86),  a  facility  of 
reduction  is  even  one  of  the  characters  of  this  frac- 
ture. But  it  is  very  difficult  for  art  to  maintain  per- 
manently what  she  easily  effects  at  the  time  of 
reduction,  and  on  this  account,  our  curative  processes 
ai'e  oftentimes  insufficient. 

104.  These  processes  may  be  considered  under 
three  classes,  according  as  they  relate  1st,  to  position; 
2dly,  to  bandages;  3dly,  to  the  forms  of  apparatus 
for  making  permanent  extension. 

In  the  first  class  must  be  included  the  method 
of  Foubert,  employed  in  ancient  times,  according 
to  Louis,  and  which  consists  in  placing  the  patient 
on  a  horizontal  plain,  while  the  limb  is  secured  by 
simple  splints,  and  the  foot  by  a  kind  of  shoe.  But 
in  a  short  time  the  muscular  action,  to  which  no 
resistance  whatever  is  made,  draws  the  lovv'er  frag- 
ment upwards,  while  the  weight  of  the  body  pushes 
the  pelvis  downwards,  and  along  with  it  the  superior 
fragment.  Hence  a  new  reduction,  the  effect  of 
which  is  again  immediately  destroyed  as  at  first. 
Thus  are  new  displacements  succeeded  by  new  re- 
placements throughout  the  w^hole  course  of  the 
treatment. 

105.  This  method,  almost  universally  adopted 
in  latter  times,  and  appro\'ed  of  by  Louis,  was  in 
vogue  at  the  hospital  of  Charity,  when  Desault  en- 


c 


272 

tered  it.  Ought  we  then  to  be  sui*prised,  that  the 
fracture  was  considered  as  incurable?  Here  indeed 
the  plainest  and  most  important  indication  is  evident- 
ly disregarded.  Nothing  to  retain  the  fragments  in 
apposition,  nothing  to  prevent  them  from  being  con- 
stantly moved.  Does  not  the  method  of  Foubert 
very  closely  resemble  those  experiments,  in  which, 
the  bone  of  an  animal  is  broken  intentionally,  and 
then  to  prevent  a  reunion  and  form  an  artificial 
joint,  the  fragments  are  kept  inconstant  motion? 

106.  Will  any  better  success  attend  the  method 
of  securing  the  leg,  as  Dalechamp  recommends,  to 
the  foot  of  the  bed?  In  such  a  case  the  trunk  and 
the  pelvis  glide  down  along  the  inclined  plain  made 
by  the  pressure  of  the  nates  (14),  and  hence  a  con- 
stant cause  of  the  shortening  of  the  limb. 

107.  The  second  class  of  curative  means,  includes 
different  forms  of  apparatus  simply  retentive.  Pare, 
Petit,  and  Heister,  recommend,  as  most  useful,  the 
Spica  of  the  groin.*  But  what  effect  can  this  pro- 
duce ?  What  force  applied  in  that  part  can  keep  the 
lower  fragment  down,  and  the  pelvis  up,  secure  the 
immobility  of  the  hmb,  and  prevent  its  rotation  out- 
wards? If  the  bandage  be  tight,  it  will  compress  the 
muscles  unequally,  make  them  contract,  and  tlius 
become  the  cause  of  a  contraction  or  shortening  of 
the  limb.  In  some  respects,  there  is  more  advantage 
to  be  derived  from  the  tin  case  lined  with  cloth  on 
its  inside,  which  Fabricius  of  Hilden  applied  to  the 
external  part  of  the  thigh ;  a  method  which  has  been 

*  Le  Sjiica  de  I'aine.  Trans. 


273 

renewed  since  his  time,  by  certain  celebrated  practi- 
tioners of  Germany ;  from  the  pasteboard  case  pro- 
posed by  Duvemey  as  a  substitute  for  that  of  tin ; 
from  the  retentive  plaster*  of  Buffle  employed  like- 
wise by  Arnaud;  and  from  the  splints  adopted  by  most 
practitioners.  But  can  these  means,  (so  differently 
varied  in  form,  yet  still  the  same  in  their  action),  while 
they  prevent  displacement  laterally  or  in  the  cross- 
direction  of  the  bone,  prevent  it  also  in  the  longitudi- 
nal direction,  which  latter  ought  to  be  the  principal 
object  in  view?  Will  they  miake  any  resistance  to 
the  muscular  action?  See  what  has  been  already  said 
on  splints,  bandages,  &c.  (89.. ..95), 

108.  The  insufficiency  of  these  forms  of  appara- 
tus, arises  from  their  not  being  constructed  with  a 
prbper  view  or  reiference  totlie  general  principle  that 
ought  to  be  observed  in  the  treatment  of  every  frac- 
ture; namely  ,^  that  the  means  intended  to  prevent 
displacement,  ought  to  be  founded  on  the  causes  that 
produce  it.  But,  these  causes  here,  are,  1st,  The  ac- 
tion of  the  muscles  which  draw  the  lower  fragment 
upwards :  2dly,  The  weight  of  the  body  which  pushes 
the  pelvis  downwards :  3dly,  The  weight  and  direc- 
tion of  the  foot  and  leg,  which  tend  to  carry  the  toes 
outwards  by  a  rotatory  motion.  Hence,  the  threefold 
indication  or  end  of  every  apparatus,^  is,  1st,  To  keep 
the  body  of  the  bone  down :  2dly,  To  retain  the  pel- 

*  fL'ecusson.J  The  literal  meaning  o£  this  word  is  an  es- 
cutcheon, or  a  coat  of  arms.  But  when  used  in  surgical  lan- 
guage, it  signifies  a  retentive  or  strengthening  plaster.  Such  I 
conceive  its  meaning  to  be  in  the  present  instance. 

Trans. 
36 


274 

vis  up :    and  3dly,  To  secure  the  foot  nearly  in  a 
right  line  with  the  leg. 

109.  The  first  consideration  leads  us  naturally  to 
the  second.  The  means  destined  to  fulfil  this  threes 
fold  indication,  must  be  constant  in  their  action, 
since  the  causes  which  they  have  to  combat  act  with- 
out remission.  Hence  the  necessity  of  an  apparatus 
for  permanent  extension.  See  what  has  been  said  ott 
the  nature  of  this  expedient  (46.... 51),  on  the  differ- 
ent modes  of  effecting  it  (52.... 57),  and  particularly 
on  the  mode  pursued  by  Desault  (5 8.... 70). 

1 10.  The  mechanism  of  his  apparatus  for  perma- 
nent extension  is  the  same  here  as  in  fractures  of  the 
body  of  the  bone.  The  limb  is  secured  against  a 
strong  splint,  to  the  two  ends  of  which  t^ro  rollerSy 
nmning  one  from  the  pelvis,  and  the  other  fi-om  the 
foot,  are  firmly  tied.  The  first  of  these  rollers  holds 
the  pelvis  up,  and  the  second  di'aws  the  foot  down : 
hence  the  two  first  indications  are  fulfilled.  The  third 
is  also  fulfilled  by  the  extension  of  the  limb,  which 
prevents  its  rotation  outwards,  by  means  of  the  out- 
side splint,  which  passing  beyond  the  sole  of  the  foot 
keeps  it  immoveable. 

111.  The  bandage  of  strips  and  compresses, 
which  in  fractures  of  the  body  of  the  bone,  are  pre- 
viously applied  round  the  limb,  and  oppose  in  some 
measure  its  motions  laterally,  are  here  entirely  use- 
less. Being  all  indeed  applied  on  the  lower  fragment, 
what  purpose  could  they  answer  towards  fixing  it 
against  the  upper  one  ?  They  could  do  nothing  but- 
compress  the  muscles,  and  by  that  means  diminish 
their  power  of  contraction :  but  extension  alone  pro- 


S7S 

duces  this  effect.  Desault  rejected  the  bandage  alto- 
gether, and  contented  himself  with  the  use  of  spHnts 
and  bolsters,  as  appears  frora  the  following  case  re- 
ported by  Couteau. 

Case  VI.  Maria  Nof,  as  she  was  running  on 
the  ice,  in  the  severe  winter  of  1788,  slipped,  and 
laUing  on  the  great  trochanter,  fractured  the  neck  of 
the  OS  femoris.  She  was  immediately  carried  to  the 
Hotel-Dieu,  where  the  signs  formerly  mentioned 
(60....  66)  disclosed  at  once  the  nature  of  her  disease. 
The  shortening  of  the  limb  was  less  than  in  ordinary 
cases. 

The  apparatus  was  applied  in  the  following  man- 
ner. The  junk-cloth,  the  body-bandage,  and  the  bits 
of  tape,  were  laid  on  the  bed,  in  the  order  already 
mentioned  (60) :  the  patient  was  then  placed  in  such 
a  manner  that  the  affected  thigh  corresponded  exact- 
ly to  the  middle  of  them.  The  reduction  being 
eflPected,  the  two  splints  were  applied,  one  on  the  ex- 
ternal and  the  other  on  the  internal  side  of  the  limb ; 
on  each  side,  and  along  the  anterior  part  of  the  thigh, 
the  bolsters  were  laid:  three  bits  of  tape  for  the  leg, 
four  for  the  thigh,  and  the  body-bandage  for  the 
pelvis,  served  to  secure  the  splints.  One  end  of  a 
roller,  which  had  been  previously  fixed  on  the  upper 
side  of  the  foot,  passing  through  the  mortise  on  the 
external  splint,  and  being  tied  to  the  other  end  Vv^hich 
passed  thi'ough  the  hollow  or  notch,  produced  exten^ 
sion,  while  counter-extension  was  made  by  means 
of  another  roller  directed  obliquely  from  the  tubero- 
sity of  the  ischium  over  the  superior  part  of  the  same 
splint,  which  it  drew  downwards.  This  w^as  the  same 


276 

apparatus  formerly  described  (60.... 66),  ^cept  as 
to  the  bandage  of  strips,  the  compresses,  and  the  an- 
terior splint,  which  running  only  from  the  fold  of  the 
groin,  had  no  effect  in  retaining  the  fragments. 

The.  treatment  was  simple.  No  general  disease 
of  the  system  existing,  the  patient  returned,  in  a  few 
days,  to  her  usual  regimen.  Being  visited  every  day, 
the  appai'atus  was  frequently  tightened;  and  was  re- 
newed six  times  at  different  intervals. 

A  bilious  disposition  shewed  itself  on  the  seven- 
teenth day.  This  was  removed  by  an  emetic  given  in 
solution,  and  after  this  nothing  remarkable  occurred. 
On  the  fifty-second  day  the  state  of  the  parts  was  ex- 
amined. The  consolidation  was  almost  accomplished? 
by  the  sixtieth  day  it  was  complete,  and  the  patient 
was  discharged  a  few  days  afterwards,  experiencing 
only  a  slight  degree  of  lameness. 

§XVIL 

OF  TH£   SUBSEQUENT   TREATMENT. 

112.  It  is  more  essential  here  than  in  fractures  of 
the  body  of  the  os  femoris,  to  keep  up  extension  with 
the  utmost  exactness,  because,  in  the  present  case,  a 
much  greater  number  of  muscles  being  attached  to 
the  lower  fragment,  very  gi-eatly  augment  the  powers 
tending  to  displace  it»  Hence  the  necessity  of  exa- 
mining the  apparatus  every  day,  to  see  whether  or  not 
any  shortening  of  the  limb  has  occurred,  to  tighten, 
if  they  be  relaxed,  the  rollers  that  make  extension, 
and  to  renew  the  application  of  the  whole,  if  it  be  in 
any  measure  deranged. 


277 

113.  The  proper  treatment  here,  as  well  as  io 
most  other  fractures,  consists  more  in  these  atten- 
tions, taken  collectively,  than  in  the  use  of  internal 
means.  It  is  to  the  want  or  neglect  of  such  attentions, 
that  we  ought  to  attribute  the  little  success  obtained 
by  many  surgeons  from  the  bandage  of  Desault. 

Case  VII.  A  man,  having  fractured  his  thigh  by 
a  faU,  called  in  a  surgeon,  who,  reducing  the  fracture, 
and  retaining  it  by  this  bandage,  examined  the  state 
of  the  parts  every  day,  and  finding  no  derangement  of 
the  splints,  neglected  attending  to  the  rollers  destined 
for  making  extension.  Seventh  day,  a  shortening  of 
two  inches;  a  new  reduction,  and  a  new  application 
of  the  bandage ;  the  same  want  of  attention  as  before ; 
the  same  shortening  at  the  expiration  of  a  few  days; 
the  means  were  then  rejected,  and  declared,  in  a  pub- 
lication, to  be  insufficient.  How  often  do  processes 
and  modes  of  practice  of  great  utility,  by  being  trans- 
mitted from  person  to  person,  or  from  book  to  book, 
lose  at  length,  that  credit  they  are  entitled  to,  and  that 
approbation  which  they  ought  to  command ! 

114.  Serious  accidents  so  seldom  accompany 
fractures  of  the  neck  of  the  os  femoris,  that  there  is 
no  necessity  of  employing  numerous  means  to  remove 
them.  A  diet  somewhat  strict  for  a  few  days,  dilut- 
ing drinks,  and  then  a  return  to  the  patient's  usual 
mode  of  living,  unless  something  besides  the  fracture 
should  forbid'it,  constituted  the  simple  treatment  pur- 
sued by  Desault  in  common  cases.  Any  varieties 
resulting  from  accidental  circumstances,  must  fall 
under  the  general  treatment  of  fractures. 


278 

115.  The  period  necessary  for  the  healing  of  frac- 
tures of  the  neck  of  the  os  femoris,  is  represented  by 
most  authors  as  being  longer  than  the  term  required 
in  other  similar  affections.  We  read,  in  the  Memoirs 
of  the  Academy  of  Surgery,  that  oftentimes  the  cure 
is  not  complete  in  less  than  three  or  four  months. 
The  reason  of  this  will  be  evident,  if  we  consider,  on 
the  one  hand,  that  the  reunion  is  always  more  tedious, 
in  proportion  as  the  contact  of  the  fragments  is  more 
frequently  interrupted :  and,  on  the  other,  that,  in  the 
means  formerly  employed,  there  was  nothing  opposed 
to  the  powers  of  displacement.  Hence  it  follows,  that, 
if  skilfully  treated,  this  fracture  ought  to  follow  nearly 
the  same  course  with  others.  It  is  this  that  confirmed 
the  superior  excellence  of  the  practice  of  Desault, 
who  almost  always  obtained  a  cure,  all  other  things 
being  equal,  such  as  age,  strength  of  constitution,  &c. 
in  the  space  of  forty-five  or  fifty-five  days. 

116.  We  discover,  in  general,  that  the  cure  is 
complete,  from  a  disappearance  of  the  signs  of  the 
fracture,  more  particularly  from  the  motions  of  the 
great  trochanter,  in  which  circumduction*  succeeds 
to  rotation  on  its  own  axis,  when  the  limb  is  made  to 
move  on  itself,  that  is,  to  rotate  oatwards  or  inwards. 
The  power  of  standing  and  Vvalking  is  an  infallible 
evidence  of  this  reunion;  nor  are  these  exertions 
practicable,  till  the  expiration  of  some  time  after  it  is 
completed;  this  circumstance  is  owing  to  a  stiffness 
remaining  in  the  parts  around  the  joint,  occasioned 
hy  long  extension  and  a  want  of  motion,  and  which 

*  A  motion  or  sweep  describing  the  arch  of  a  circle.    Trans-, 


279 

exercise  alone  can  effectually  remove*  (See  what  lias 
been  already  said  on  this  subject,  in  several  parts  of 
this  work.) 

117.  Numerous  cases  may  be  adduced  in  favour 
©f  the  doctrine  laid  down  in  this  memoir.  But  a  suf- 
ficient number  have  been  already  published  in  the 
Journal  of  Surgery.  I  shall  subjoin  only  two,  drav^^n 
up  by  Manoury  and  Seveille. 

Case  VIII.  Maria  ***,  aged  forty,  falling  on 
the  great  trochanter,  experienced  a  sudden  pain,  and 
heard  a  considerable  report :  she  rose,  however,  and 
with  difficulty  made  her  way  home.  On  the  day  fol- 
lowing, a  shortening  of  an  inch  was  perceived  in  her 
tliigh :  the  great  trochanter  was  drawn  backward  and 
upward:  walking  was  now  impracticable,  the  foot 
remained  turned  inwards.  Notwithstanding:  this  lat- 
ter  circumstance,  Desault,  being  called  to  the  patient, 
declared  that  a  fracture  existed,  which  was  evidenced 
in  particular  by  a  rotatory  motion  of  the  great  tro- 
chanter on  its  own  axis.  The  necessary  apparatus 
being  applied,  was  carefully  e]stamined  eveiy  day  by 
Manoury,  to  whom  the  patient  was  intrusted.  No 
shortening  of  the  limb  occurred,  nor  did  any  unfa- 
vourable accident  supervene,  and,  by  the  thirty-ninth 
day,  the  fracture  was  exactly  and  firmly  united ;  on 
the  forty -third,  the  splints  were  removed ;  and  on  the 
fiftieth,  the  patient  could  walk  without  assistance. 

Case  IX,  John  Rignal  fractured  the  neck  of  the 
OS  femoris  by  falling,  not  as  in  the  preceding  case, 
on  the  great  trochanter,  but  on  the  knee,  which  was 
bent  at  the  time  of  the  fall,  while  the  shoulder  of  the 
same  side  supported  a  heavy  load.    He  was  brought 


280 

to  the  Hotel-Dieu,  where  the  same  signs,  as  m  the 
preceding  case,  (except  that  here  the  foot  was  turned 
inwards)  furnishing  ground  for  the  same  diagnosis, 
gave  rise  to  the  same  treatment,  which,  in  fifty  days, 
was  followed  by  a  result  equally  favourable. 


FRACTURES  OF  THE  LOWER  EXTRE-  , 
MITY  OF  THE  OS  FEMORIS. 

118.  The  lower  extremity  of  the  os  femoris,  be- 
ing thicker  than  the  rest  of  the  bone,  and  protected 
from  the  action  of  external  bodies  by  a  thinner  cover- 
ing of  soft  parts,  is  yet  better  secured  from  fractures 
than  the  other  paits,  for  the  following  reasons :  1st, 
because  counter-strokes,  so  frequently  the  cause  of 
fi-actures  of  the  body  and  neck  of  the  bone,  can  affect 
this  part  but  rarely :  2dly,  because  the  os  femoris, 
being  more  moveable  at  a  distance  from  the  centre 
erf  its  motions,  yields  more  easily  to  whatever  strokes 
and  impressions  it  there  recieves:  3dly,  because 
motion,  when  distributed  through  a  greater  bulk  of 
matter,  has  less  power  to  destroy  its  continuity. 

§  XVHI. 

OF   THE   VARIETIES  AND   THE    CAUSES. 

119.  The  fractures  which  occur  in  the  lower 
extremity  of  the  os  femoris,  ai'e  of  two  kinds  very 
different  from  each  other.  Sometimes  situated  above 
the  condyls,  they  only  separate  these  from  the  body 
of  tlie  bone:  at  other  times,  affecting  the  condyls 


281 

themselves,  they  extend  into  the  very  joint.  My 
attention  shall  at  present  be  confined  exclusively  to 
the  latter  kind,  as  the  other  may,  in  almost  every 
respect,  be  classed  with  the  fractures  which  have 
been  already  considered.  Most  authors  have  neglect- 
ed to  treat  of  fractures  of  this  kind,  under  a  distinct 
head,  from  a  persuasion,  that,  owing  to  their  com- 
munication with  the  joint,  they  ought  to  be  ranked 
among  complicated  fi-actures,  which  are  known  to 
require  a  mode  of  treatment  very  different  from  that 
employed  in  such  as  are  simple.  But  I  shall  pre- 
sently show  what  regard  ought  to  be  paid  to  this 
ancient  opinion. 

120.  The  division  presents  itself,  in  general, 
under  two  different  forms:  1st,  runfting  obliquely 
frpm  above  downwards,  and  from  within  outwards 
or  from  without  inwards,  it  may  separate  a  greater 
or  smaller  portion  of  one  of  the  condyls  from  the 
rest  of  the  bone :  2dly,  these  two  bony  protuberances 
may  be  divided  from  each  other  by  a  longitudinal 
fracture,  meeting  another  transverse  or  oblique  frac- 
ture, which  by  either  passing  through  the  whole 
tliickness  of  the  bone,  separates  botii  condyls  from 
it,  or  extending  only  half  way  through  it,  separates 
but  one  of  them.  The  fracture  is  single  in  the 
first  case,  but  double  in  the  second..  The  latter 
occurs  in  practice  more  frequently  than  the  former^ 
Both  are  usually  produced  directly,  that  is,  by  the 
immediate  action  of  external  bodies.  Yet  the  follow- 
ing fact  seems  to  evince  that  the  accident  may,, 
possibly  at  least,  arise  from  a  counter  stroke. 

37 


282 

Case  X.  The  corpse  of  a  man  of  forty,  was 
brought  into  the  amphitheatre  of  Desault,  soon 
after  he  became  a  pubhc  teacher.  One  of  the  pupils, 
on  preparing  to  dissect  the  body,  discovered  a  pre- 
ternatural mobility  in  one  of  the  condyls.  The  knee 
was  examined.  A  double  fracture  was  found,  ac- 
companied  by  a  separation  of  the  two  condyls.  On 
inquiry  it  was  ascertained  that  the  corpse  came  from 
the  Hotel-Dieu.  It  was  further  discovered,  with 
certainty,  that  the  injured  subject,  in  jumping 
tlii'ough  a  window,  had  alighted  on  his  feet,  and 
that  he  experienced  instantly  a  severe  pain  in  his 
knee,  and  fell  on  the  ground,  unable  to  support 
himself. 

Here,  no  doubt  but  the  condyls,  by  being  vio, 
lently  pressed  between  the  weight  of  the  body  and 
the  articulating  surfaces  of  the  tibia,  had  been  frac- 
tured by  a  counter-stroke. 

§  XIX. 

OF   THE   SIGNS. 

121.  But  whatever  may  be  the  precise  form  and 
figure  of  the  fracture,  its  signs  are  easily  compre- 
hended: a  very  perceptible  separation  oftentimes 
exists  between  the  two  condyls,  increasing  the  trans- 
verse diameter  of  the  knee.  The  rotula,  sinking 
into  this  chasm  between  the  condyls,  renders  the 
part  more  fiat  from  before  backwards,  than  it  is  in 
its  natural  state.  If  the  rotula  be  pressed  in  a  back- 
ward direction,  the  condyls  are  separated  still  further 
from  each  other.    If,  on  the  other  hand,  pressure  be 


283 

made  on  each  side  t)f  the  lower  part  of  the  os  femo- 
fiis,  the  condyls  are  brought  together,  and  the  knee 
resumes  its  usual  shape.  If  we  take  hold  of  a  con- 
dyl  in  each  hand,  it  will  be  easy,  by  moving  them 
alternately  backward  and  forward,  to  make  them 
rub  against  each  other,  and  produce  a  crepitation, 
which  characterizes  the  fracture  beyond  a  doubt. 

122.  If  the  upper  fracture  be  oblique,  a  shorten- 
ing of  the  limb  more  or  less  perceptible  is  always 
the  effect  of  it :  this  appears  to  be  principally  owing 
to  the  weight  of  the  body  which  pushes  the  upper 
fegment  down,  and  to  the  action  of  the  muscles 
which  draws  the  lower  ones  up  (10....  14).  In  this 
case,  the  superior  fragment,  being  forcibly  pushed 
against  the  integuments,  has  sometimes  lacerated, 
and  even  passed  through  them,  giving  rise  to  con- 
sequences of  a  serious  nature.  Desault  has  publish- 
ed a  case  of  this  kind.  A  similar  effect  has  been 
produced,  though  more  rarely,  by  the  inferior  frag- 
ment, in  which  case  much  mischief  has  arisen  from 
tlie  admission  of  air  into  the  joint. 

123.  Sometimes  when  tJie  upper  fracture  extends 
through  the  whole  thickness  of  the  os  femoris,  the 
Extremity  of  the  bone  is  turned  round,  so  that  the 
external  condyl  lies  behind,  the  internal  before,  and 
the  rotula  on  the  outside,  while  the  foot  points  in 
the  same  direction.  A  case  of  this  kind  is  recorded 
in  the  Journal  of  Surgery.  The  body  of  the  bone, 
being  pressed  into  the  chasm  or  interval  between 
the  two  condyls,  may  prevent  their  reunion,  by 
pushing  them  asunder,  and  thus  gi^'e  rise  to  various 
accidents. 


284 

124.  Most  of  these  phenomena  will  fail  to  occur, 
if  the  upper  division,  passing  only  half  way  through 
the  bone,  break  off  but  one  of  the  condyls,  or  if^ 
passing  tlirough  even  the  whole  of  the  bone,  it  be 
perfectly  transverse;  but  cases  of  this,  description 
are  seldom  met  with. 

§XX. 

OF   THE   PROGNOSIS. 

125.  I  have  httle  to  add  to  the  observations 
already  made  on  the  prognosis  in  fractures  of  the 
condyls  of  the  os  humeri.  All  that  I  have  there 
said  is  applicable  to  the  os  femoris.  As  is  the  case 
with  regard  to  the  former  fractures,  so  also  here, 
die  apprehensions  of  authors  have  been  greatly  ex- 
aggerated by  their  visionary  doctrine  respecting  in- 
juries of  the  joints :  both  reason  and  experience  unite 
in  showmg  such  apprehensions  to  be  unfounded. 

I  shall  only  observe,  that  in  the  present  case, 
even  more  particularly  than  in  fractures  of  the  con- 
dyls of  the  OS  humeri,  most  of  the  unfortunate  events 
that  take  place,  are  owing  to  the  insufficiency  of  the 
means  employed  for  effecting  a  cure.  Indeed,  as  I 
have  already  observed  (45),  all  those  means  can 
have  no  effect  in  opposing  the  continual  tendency  of 
the  fragments  to  become  displaced,  if  the  upper  frac- 
ture* of  the  OS  femoris  be  oblique.  And  in  most 
cases,  this  fracture  is  oblique :  hence  it  follows,  1st, 

*  That  which  forms  the  superior  boundaiy  of  the  longi- 
tudinal fracture  by  Avhich  the  condyls  ^re  separated  from  each, 
other^  Trans.. 


285 

that  the  bony  points  of  the  fragments  being  con- 
stantly pushed,  during  their  displacement,  against 
the  ligaments  that  surround  the  joint,  will  perpetuate 
in  them  the  irritation  first  produced  by  the  firacture, 
and  thus  give  rise  to  swelling,^  inflammation,  and  all 
the  other  morbid  affections  of  the  part,  so  much 
dreaded  by  authors,  and  attributed  by  them  to  the 
mere  communication  of  the  fracture  with  the  joint: 
2dly,  that  the  best  expedient  to  prevent  such  affec- 
tions, is  an  apparatus  that  shall  retain  the  divided 
surfaces  in  perfect  contact  with  each  other  by  means 
of  permanent  extension, 

126.  It  is  obvious  that  this  extension  wdll  be  less 
necessary,  if  the  upper  division  of  the  os  femoris  be 
transverse,  because,  then,  the  condyls  and  the  body 
of  the  bone  will  find  a  mutual  point  of  support  against 
each  other. 

^  XXL 

OF  THE  MEANS  OF  CONTACT  BETWEEN  THE 
FRAGMENTS. 

127.  Since  the  same  caTises,  as  in  the  preceding 
cases,  tend  here  to  destroy  this  contact,  when  the  su- 
perior fracture  is  oblique  (122),  the  apparatus  ought, 
therefore,  to  be  so  constructed  as  to  counteract  these 
causes,  that  is,  it  ought,  1st,  to  draw  the  two  condyls 
down  ,•  2dly,  to  retain  the  pelvis  up,  and  with  it  tlie 
superior  fragment.  This  twofold  indication  relates 
only  to  the  upper  division  of  the  bone,  without  any 
reference  to  that  which  separates  the  condyls ;  3dly, 
it  is  necessary  to  counteract  the  tendency  which  the 
condyls  may  have  to  separate  from  each  other. 


286 

128.  Penticineiit  extension,  made  in  the  manner 
already  mentioned  (60.... 63),  fulfils  the  two  first  in- 
dications ;  while  two  lateral  splints,  and  the  bandage 
of  strips  fulfils  the  third.  Desault,  therefore,  applied 
to  this  particular  case  his  apparatus  for  permanent 
extension,  modified  only  in  svich  a  way,  that,  instead 
of  terminating  at  the  knee,  the  bandage  of  strips  was 
continued  to  a  distance  down  the  leg,  in  order  that  its 
action  might  be  the  more  efficacious.  For,  it  is  well 
kno^'m,  that  it  is  at  its  middle  part  that  the  firmness 
and  retenti\Te  power  of  a  bandage  are  greatest,  because 
the  casts  of  the  roller  at  the  upper  and  lower  ends, 
serve  to  secure  those  in  the  middle.  The  upper  splint 
being  altogether  useless,  was  not  employed. 

129.  If  the  superior  fracture  be  transverse,  the 
condyls,  as  I  have  already  said,  meet  with  resistance 
against  the  body  of  the  bone,  while  they,  on  the  other 
hand,  support  it  in  such  a  manner,  as  to  prevent  it 
from  descending,  though  pushed  by  the  weight  of 
the  body  along  the  inclined  plain  made  by  the  press- 
ure of  the  nates.  Here,  then,  permanent  extension  is 
generally  useless,  and  all  that  is  necessary  is,  to  re- 
tain the  cond}' Is  and  prevent  their  separation  by  means 
of  lateral  pressure.  The  same  apparatus  may  still  be 
employed,  provided  the  two  rollers  for  extension  be 
laid  aside. 

130o  If  a  wound  in  the  soft  paits  accompany  the 
fi^acture,  whether  it  be  produced  by  the  same  cause, 
or  by  the  subsequent  passage  of  tlie  fragments 
through  the  integuments,  and  v^hether  it  communi- 
cate with  the  articulation  or  not,  it  is  necessar}*,  as 
soon  as  suppuration  has  taken  place,  to  renew  the 


287 

dressings  ever}'  day  or  every  other  day,  taking  care, 
in  the  mean  time,  to  supply,  by  the  hands  of  an  as- 
sistant, the  want  of  extension  by  means  of  the  appa- 
ratus. The  following  case,  extracted  from  the  Jour- 
nal, exhibits  a  specimen  of  the  treatment  that  ought 
to  be  adopted  in  similar  cases. 

Case  XI.  Claudius  Legrange,  aged  thirty-one, 
and  of  a  sound  constitution,  was  wounded  by  the 
kick  of  a  horse,  on  the  internal  condyl  of  the  left  os  fe- 
moris.  The  violence  of  the  pain  obliged  him  to  throw 
himself  on  a  heap  of  straw,  that  lay  at  a  little  distance, 
and  which  he  reached  by  hopping  on  his  right  foot. 
The  pains  were  augmented  by  this,  for  at  each  step, 
the  thigh  being  alternately  bent  or  extended  at  the 
injured  part,  was  moved  sometimes  backward  and 
sometimes  forward.  The  patient  was  brought  to  the 
Hotel-Dieu,  a  few  hours  after  the  accident. 

The  signs  already  specified  (121  and  122)  an- 
nounced to  Desault,  a  longitudinal  fracture  separat- 
ing the  two  condyls,  and  terminated  above  by  another 
fracture  of  the  body  of  the  bone,  which  descended 
obliquely  from  about  five  inches  above  the  external 
condyl,  to  withm  two  inches  of  the  internal  one. 

The  muscles  of  the  thigh,  by  means  of  violent 
contraction,  had  drawn  that  portion  of  the  os  femoris 
attached  to  the  external  condyl  upwards,  and  the  su- 
perior fragment  downwards.  The  sharp  point  of  the 
latter  had  passed  through  the  skin,  and  produced  a 
wound  of  an  inch  and  a  half  in  extent,  on  the  inside 
of  the  thigh,  and  a  little  above  the  condyl. 

The  patient  being  undressed,  was  placed  on  a 
bed  nearly  horizontal,  on  which  had  been  previously 


288 

spread  the  necessary  pieces  of  apparatus,  disposed  in 
proper  order.  Desault  then  examined  the  wound, 
extracted  a  sphnter  of  the  bone,  covered  the  wound 
with  hnt,  and  then  proceeded  to  the  apphcation  of  the 
apparatus  which  he  usually  employed  in  such  cases 
(128). 

The  extension  was  accompanied  by  no  pain :  on 
the  other  hand,  it  gave  immediate  relief:  diluting 
diinks  were  prescribed.  Next  day,  no  pain ;  pulse  a 
little  raised;  no  diyness,  nor  any  alteration  of  the 
skin ;  diet  the  same  as  on  the  preceding  day ;  the  ap- 
pai-atus  wet  with  vegeto- mineral  water.  Fourth  day, 
a  new^  application  of  the  apparatus,  which  had  become 
relaxed;   appearances  of  suppuration. 

From  this  time  the  dressing  was  renewed  every 
other  day,  till  the  sixteenth,  when  the  wound  w^as  cica- 
trized. After  this  the  apparatus  was  not  touched  except 
u^en  deranged;  it  was  only  wet  from  time  to  time  with 
vegeto- mineral  water,  and  great  pains  were  taken  to 
keep  up  the  extension.  The  apparatus  was  not  laid 
aside  till  the  sixty-fourth  day,  although  the  callus  ap- 
peared to  have  acquired  a  state  of  solidit}^  som^ewhat 
sooner. 

The  patient  M^as  soon  in  a  situation  to  take  exer- 
cise. The  stiffness  then  disappeared  rapidly,  and,  in 
about  tliree  weeks,  he  left  the  hospital,  able  to  bend 
the  leg  to  a  right  angle  with  the  thigh,  and  under  a 
full  confidence  that  he  would  in  a  short  time  regain 
all  the  motions  of  the  limb. 


289 
§  XXII. 

OF  THE    SUBSEQUENT   TREATMENT. 

131.  As  soon  as  the  consolidation  is  complete,  the 
motions  of  the  hmb  must  commence.  These,  at  first 
gentle  and  confined,  must  be  afterwards,  increased  in 
extent,  and  more  frequently  repeated,  till,  at  length, 
the  limb  should  be  exercised  every  day  for  two  oi: 
three  hours  without  intermission.  The  position  and 
direction  of  the  leg  ought  to  be  constantly  changed. 
One  while,  the  thigh  should  be  elevated  by  a  bolster, 
so  as  to  flex  the  leg;  at  another  time,  the  bolster 
should  be  fixed  under  the  leg  to  keep  it  extended.- 
The  rotula  must  be  moved  in  every  direction,  and, 
as  soon  as  the  patient  can  leave  his  bed,  he  should 
take  exercise  himself.  These  precautions  ai'e  more 
necessary  here  than  in  any  other  fi^acture,  because  a 
stiffness  of  the  parts  adjacent  to  the  jomt,  is  always 
the  inevitable  consequence  of  a  long  state  of  rest. 
Certainly  writers  would  not  have  considered  anchy- 
losis as  the  most  favourable  termination  of  such  fi-ac- 
tures,  had  they  been  acquainted  with  the  effect  of  ex- 
ercise and  rest  in  that  now  under  consideration. 

132.  Provided  the  mode  of  treatment  here  laid 
down  be  faithfully  pursued,  the  affection  is  seldom 
accompanied  by  those  numerous  accidents,  of  which 
so  much  has  been  said.  The  callus  is  formed  in  the 
usual  manner:  and,  on  some  occasions,  where  the 
patients  have  died  at  the  Hotel-Dieu,  in  consequence 
of  some  affection  not  connected  with  the  fi-acture,  the 

two  condyls  have  been  found  perfectlv  united  together 

38 


290 

and  to  the  body  of  the  bone.    An  instance  of  this  kind 
is  recorded  in  the  Journal  of  Surgery. 

133.  Let  us,  in  the  mean  time,  not  speak  too 
favourably  of  that,  respecting  which  the  ancients  were 
accustomed  to  speak  too  unfavourably.  Even  the 
practice  of  Desault  would  expose  our  en'or.  Some- 
times the  most  assiduous  attention,  and  the  most 
carefiil  application  of  the  apparatus,  have  not  been 
sufficient  to  prevent  abscesses  around  the  knee,  and 
an  anchylosis  of  the  joint*  Desault  related  a  case 
where  even  a  caries  of  the  articulating  surfaces  occur- 
red. But  some  extraneous  circumstances  appeared 
to  have  an  influence  in  these  instances :  and  it  may  be 
laid  down  as  a  general  rule,  that  fractures  of  the  lower 
extremity  of  the  os  femoris,  require  the  same  treat- 
ment with  fractures  of  its  other  parts » 


291 


EXPLANATION  OF   THE   SECOND   PLATE.* 

This  figure  represents  the  apparatus  for  permanent 
extension,  employed  by  Desault  in  obUque  frac- 
tures of  the  OS  femoris. 

AA.  The  external  splint,  with  a  notch  and  a  mortise 
in  it  at  the  lower  end  to  fix  the  inferior  extend- 
ing roller. 

BB.  A  bandage  passing  round  the  body,  intended  to 
secure  this  splint  against  the  pelvis. 

CC.  The  anterior  splint,  reaching  only  to  the  knee. 

dddd.  The  anterior  bolster,  extending  along  the 
whole  limb,  and  secured  by  pieces  of  strong  tape. 

EE.  A  portion  of  the  bandage  of  strips,  seen  between 
the  anterior  and  dac  external  lateral  bolsters. 

FF.  The  junk-cloth  intended  to  be  folded  round  the 
two  lateral  splints. 

g  g.  The  superior  extending  roller,  passing  round  the 
end  of  the  external  splint,  and  fixed  underneath 
on  the  tuberosity  of  the  ischium. 

H.  The  sub-femoral  roller  or  strap,  intended  to  pre- 
vent the  bandage  BB,  which  passes  round  the 
body,  from  slipping  upwards. 

K  k.  A  roller  usually  passed  round  the  foot,  to  pre- 
vent it  from  turning. 

L.  The  inferior  extending  roller,  fixed  in  the  mortise 
and  the  notch  of  the  external  splint. 

*  For  an  account  of  an  improvement  of  the  splint,  repre- 
sented in  this  plate,  projected  by  Dr.  Physick,  and  now  used  in 
the  Pennsylvania  hospital,  see  Article  IL  of  the  Appendix. 

Trans, 


292 


THOUGHTS 

ON  LUXATIONS  OF  THE   OS  FEMORIS,  UPWARD 
AND   FORWARD. 

1.  Few  kinds  of  luxation  of  the  os  fcmoris 
occur  in  practice  more  rarely  than  this.  Practitioners 
•who  have  seen  it,  and  those  who,  on  the  authority  of 
others,  have  described  it,  without  having  seen  it,  have 
all  given  an  unfavourable  prognosis  respecting  it,  for 
the  following  reasons:  1st,  on  account  of  the  inevit- 
able rupture  of  the  round  ligament :  2dly,  on  account 
of  the  distension,  and  even  laceration  of  the  capsule, 
and  of  the  compression  and  overstretching  of  the 
nerves  and  blood-vessels:  3dly,  on  account  of  the 
great  difficulty  of  reduction.  The  following  case  will 
prove,  that  in  all  these  respects,  the  apprehensions  of 
authors  have  been  exaggerated,  that  the  obstacles  to 
reduction  arise  less  from  the  nature  of  the  displace- 
ment, than  from  the  nature  of  the  means  employed  to 
remedy  it;  and  that,  if  properly  directed,  art  would 
here  be  as  successful  as  in  other  cases. 

Case.  (Collected  by  C***).  About  the  close 
of  the  winter  which  preceded  the  death  of  Desault, 
a  porter  was  brought  to  the  Hotel-Dieu,  in  conse- 
quence of  a  fall  which  he  had  received  about  two 
hours  before,  in  the  following  manner.  As  he  was 
canying  on  his  shoulders  a  heavy  burden,  his  foot 
slipped,  while  his  leg  and  thigh  were  directed  back- 
wai'ds:  he  fell  on  his  knee,  his  thigh  maintaining 
still  the  same  direction;  so  that  the  conjoined  weight 
of  his  own  body  and  of  the  burden  which  he  caiTied, 


293 

aided  by  the  velocity  of  the  fall,  forcing  the  head  of 
the  OS  femoris,  which  pointed  at  the  time  forward 
and  upAvard,  against  the  distended  capsule,  lacerated 
it  and  drove  the  articulating  end  through  the  opening. 
Continuing  still  to  act,  it  ruptured  the  ligament, 
which  connects  the  extremity  of  the  bone  to  the  ar- 
ticulating cavit}^,  and  forced  the  head  in  front  of  the  os 
pubis,  where  it  could  be  easily  felt. 

At  the  moment  of  the  fall,  an  acute  pain  was 
felt  in  the  part;  and  the  power  of  moving  the  limb 
was  suddenly  lost;  the  patient  was  carried  home, 
where  a  surgeon  who  visited  him,  considered  the 
accident  as  a  fracture  of  the  neck  of  the  os  femoris, 
and  sent  him  to  the  Hotel-Dieu,  to  undergo  the 
necessary  treatment. 

Desault  having  examined  the  parts,  discovered, 
from  the  following  appearances,  not  a  fracture,  but 
a  luxation  upward  and  forward.  The  limb  was 
nearly  an   inch  shorter*  than  natural;  the  point  of 

*  A  case  of  luxation  of  the  head  of  the  os  femoris  in  a  for- 
ward direction,  but  differing  in  some  respects  from  the  above, 
occurred  lately  in  the  Pennsylvania  hospital  under  the  care  of 
Dr.  Physick.  The  doctor  reduced  this  luxation  in  the  amphi- 
theatre, in  the  presence  of  his  class,  by  a  process  which  was 
also  somewhat  different  from  that  adopted  by  Desault. 

In  the  case  of  Desault's  patient  the  luxated  limb  was  shorter 
than  the  sound  one :  in  that  of  Dr.  Physick's  it  was  evidently 
longer.  This  was  no  doubt  owing  to  the  head  of  the  os  femoris 
having,  in  the  former  case,  passed  farther  up  towards  the  supe- 
rior rim  of  the  OS  pubis  than  it  had  in  the  latter.  In  both  cases 
the  protuberance  formed  by  the  head  of  the  bone  in  the  groin 
could  be  readily  felt. 

For  the  purpose  of  making  counter-extension,  Desault 
passed  a  strap  bet^Yeen  the  scrotum  and  the  thigh  of  the  sound 


^94 

the  foot  was  turned  outwards;  the  thigh  being  in 
a  state  of  painful  extension,  could  not  be  flexed  on 
the  body;  adduction  and  abduction  were  alike  pain- 
ful ;  the  great  trochanter,  being  more  approximated 
than  usual  to  the  anterior  and  superior  spine  of  the 
OS  ilium,  was  also  too  far  forward;  finally,  the  pro- 
jecting head  of  the  bone  could  be  felt,  as  I  have 
already  said,  in  the  groin. 

side:  Dr.  Physick,  for  the  same  purpose,  passed  the  strap  be- 
tween the  scrotum  and  the  affected  thigh.  He  conceived  that 
hy  this  mode  he  could  act  with  more  effect  on  the  pelvis,  and 
more  effectually  prevent  the  acetabulum  of  the  affected  side 
from  being  drawn  in  any  measure  downward  by  the  extending 
forces.  It  would  seem,  that  by  making  countei'-extension,  in 
such  a  case,  on  the  sound  side,  the  pelvis  is  made  to  rotate,  so 
to  speak,  on  its  own  axis,  in  the  direction  in  which  the  counter- 
extension  is  made.  The  necessary  effect  of  this  rotation  must 
be,  a  slight  descent  of  the  acetabulum  of  the  affected  side.  But 
to  retain  the  acetabulum  firmly  up  is  the  true  and  only  end  of 
counter-extension.  Dr.  Physick  appears  therefore  to  have 
availed  himself  of  the  greatest  mechanical  advantage  of  which 
the  situation  of  the  parts  admitted. 

Again :  Desault  placed  the  strap  on  which  extension  was 
made  just  above  the  ancle :  Dr.  Physick  placed  the  strap  in- 
tended for  the  same  purpose  above  the  knee.  His  object  in  this 
was,  to  have  the  leg  free  and  unincumbered,  in  order  that  he 
might  be  able  to  use  the  limb  with  more  advantage,  as  a  lever 
of  the  first  kind,  to  assist  in  moving  the  head  of  the  os  femoris 
towards  the  acetabulum.  The  fulcram  of  the  lever  into  which 
the  limb  was  thus  converted,  was  a  strap  passed  round  the  af- 
fected thigh  a  few  inches  below  the  groin,  and  drawn  laterally 
with  great  force  in  a  direction  opposite  to  that  in  which  the 
bone  was  displaced. 

In  this  case  extension  and  counter-extension  were  made  by 
Bieans  of  powerful  sets  of  pullies.  Notwithstanding  this,  these 
ferces  were  not  alone  sufficient  to  subdue  the  resistance  of  the 


295 

The  reduction  was  eJEFected  in  the  following  man- 
ner. The  patient  being  laid  on  a  firm  table,  spread 
with  a  mattress,  a  strap  was  fastened  above  the  ancle, 
for  the  purpose  of  extension ;  another,  intended  for 
counter- extension  was  placed  between  the  scrotum^ 
and  the  thigh  of  the  sound  side,  and  brought  up  the 
back  and  front  of  the  pelvis,  along  the  body,  till  it 
passed  over  the  shoulder,  where  it  was  twisted  to- 
gether and  secured^ 

Extension  was  then  begun,  precisely  in  the 
direction  in  which  the  thigh  pointed;  and,  during 
the  execution  of  it,  a  rotatory  motion  inwards  was, 
given  to  the  limb.  At  the  expiration  of  a  few  mi- 
nutes, the  head  of  the  bone  remaining  almost  im-- 

muscles.  The  reduction  was  not  completed  till  muscular  con- 
traction had  been  weakened,  and  the  patient  reduced  almost  ta 
a  state  of  syncope,  by  the  loss  of  nearly  two  quarts  of  blood.. 
This  copious  evacuation,  co-operating  with  the  fatigue  which 
the  muscles  of  the  limb  necessarily  sustained,  in  consequence 
of  the  powerful  extension  to  which  they  were  for  some  time 
subjected  by  the  action  of  the  pullies,  overcame  all  resistance. 
and  the  head  of  the  bone  was  finally  replaced.  To  exhaust  the 
energy  of  the  resisting  muscles  by  forcible  and  permanent  ex- 
tension, and  to  weaken  the  action  of  the  systena  generally,  by 
copious  blood-letting,  appear  to  be  the  two  most  effectual 
modes  of  ensuring  success  in  the  reduction  of  all  obstinate 
cases  of  luxation. 

Another  point  of  difference  between  these  two  cases  o£ 
luxation  remains  yet  to  be  mentioned.  In  Desault's  case  the 
head  of  the  os  femoris  was,  as  he  tells  us,  displaced  in  a  direc- 
tion "  upward  and  forward."  In  Dr.  Physick's  case,  the  direc- 
tion of  the  displacement  was  downward  and  forward.  This  waa 
proved  beyond  all  doubt,  by  the  circumstance  of  the  affected 
limb  being  longer  than  the  sound  one..  Trans.. 


296 

moveable,  notwithstanding  the  efforts  to  dislodge 
it,  Desault  directed  extension  to  be  discontinued, 
and,  taking  hold  of  the  thigh,  moved  it  in  every 
direction,  with  a  view  to  enlarge  the  opening  in  the 
capsule,  the  narrowness  of  which  he  suspected  to  be 
the  cause  that  prevented  the  reduction. 

Extension  -was  then  resumed,  and  varied  in  every 
direction,  while  the  surgeon  endeavoured  to  give' 
assistance  by  pushing  the  head  of  the  bone  forcibly 
downwards,  with  his  thumbs,  and  the  palms  of  his 
hands.  Useless  efforts ;  the  displaced  bone  remained 
stationary. 

Desault  ordering  extension  to  be  again  discon- 
tinued, recommenced  the  motions  of  the  os  femoris, 
and  even  increased  their  force,  changing  them  in 
every  direction,  for  the  purpose  of  lacerating  the  cap- 
sule. After  this,  extension  was  again  renewed,  with 
better  success  than  before.  Indeed,  on  the  very  first 
effort,  the  head  resumed,  of  itself,  its  natural  situa-. 
tion,  without  any  further  assistance  on  the  part  of 
the  surgeon. 

The  sufferings  of  the  patient  ceased  almost  in- 
stantaneously ;  towards  evening  a  slight  swelling  ap- 
peared around  the  joint,  over  which  an  emollient 
cataplasm  was  applied.  On  the  day  following,  all  the 
unfavourable  symptoms  were  gone,  and  in  about  a 
fortnight  the  patient  ■v'i^as  able  to  return  to  his  usual 
exercises,  which,  however,  he  was  directed  to  pur- 
sue, for  some  time,  with  moderation. 

2.  There  ai^e,  in  this  case,  two  circumstances,  on 
which  the  practitioner  should  fix  his  attention,  and 
which  may  thi'ow  great  light  on  the  reduction  of  all 


Q91 

luxations  of  the  os  femoris,  as  they  will  be  found  ap- 
plicable to  most  accidents  of  the  kind.  These  are, 
1st,  The  naiTowness  of  the  opening  in  the  capsule. 
2dly,  The  inutility  of  the  motion  or  process  of  con- 
formation, when  that  opening  has  been  enlarged. 

3.  We  formerly  observed,  when  treating  of  lux- 
ations of  the  humerus,  that  one  of  the  obstacles  to 
reduction  was,  the  narrowness  of  the  opening  in  the 
capsule ;  the  same  circumstance  occurs  here.  That 
membrane,  lacerated  at  the  time  when  the  head  of 
the  OS  femoris  is  driven  against  it,  is  dilated  suffi- 
ciently to  let  the  head  escape :  but,  the  edges  of  the 
lacerated  membrane,  coming  together  again,  and  be- 
ing thus  drawn  tight  ai'ound  the  neck  of  the  bone, 
detain  it  in  that  position,  and  prevent  the  head  from 
re-entering  the  acetabulum.  Thus,  in  a  fracture, 
where  one  of  the  exti-emities  of  the  bone  is  protruded 
through  the  integuments,  the  opening  in  the  skin,  by 
closing  tightly  round  that  extremity,  sometimes  pre- 
vents its  reduction. 

4.  In  such  a  case,  what  is  the  first  and  most  obvi-' 
ous  indication?  It  is  necessary  to  increase  the  extent 
of  the  opening  in  the  capsule,  by  moving  the  limb  in 
every  direction.  Some  persons  haye  deemed  it  im- 
possible to  tear  this  membrane  anew.  But,  if  we 
recollect,  that  the  neck  of  the  os  femoris,  being  pla- 
ced between  the  edges  of  the  opening,  must  neces- 
sarily draw  them  asunder  by  the  motions  impressed 
on  it,  it  is  easy  to  conceive,  that  the  angles,  where 
these  edges  unite,  will  be  torn,  if  the  motions  be 
carried  to  an  inordinate  degree :  besides,  experience 
proves  here,  as  well  as  with  regard  to  the  humerus, 

39 


298 

the  truth  of  the  doctrine  contended  for.  Are  we  to 
apprehend,  as  these  same  persons  will  have  it,  that 
serious  accidents  may  be  produced  by  such  violent 
motions?  Experience  again  answers  in  the  negative. 
Nothing,  then,  can  be  more  certain,  than  that  this 
observation,  respecting  the  opening  in  the  capsule,  is 
a  great  stride  towards  perfection  in  the  treatment  of 
luxations  in  general,  and  particularly  of  that  now  un- 
der consideration* 

5.  When  this  obstacle  to  reduction  has  been 
removed,  it  is  then  very  readily  effected,  and  that 
without  the  process  of  conformation.  Indeed  that 
process  is  almost  always  unnecessary.  For  what  pur- 
pose should  it  be  employed?  Is  it  to  increase  the 
effect  of  extension,,  and  thus  disengage  the  head  of 
the  bone  from  the  place  which  it  accidentally  occu- 
pies? In  this  point  of  view,  it  is  nothing  but  a  very 
feeble  force,  added  to  a  very  powerful  one,  which 
receives  from  it,  therefore,  but  little  assistance :  it  is 
much  better,  if  necessary,  to  augment  the  extending 
forces  themselves*  Is  it  to  push  the  head  of  the  bone 
into  its  cavity,  after  the  extensions  have  dislodged  it? 
It  is  to  the  muscles,  and  not  to  the  efforts  of  the  sur- 
geon, that  the  performance  of  this  office  belongs.  In- 
deed, the  surgeon  must  act  altogether  in  the  dark  in 
this  respect,  as  he  cannot  possibly  ascertain  the  pre- 
cise point  where  the  opening  in  the  capsule  exists : 
he  may,  therefore,  even  push  the  head  of  the  bon& 
against  a  sound  part  of  the  capsule,  and  thus  himself 
create  an  obstacle  to  the  reduction,  which  he  is 
attempting  to  favour. 


299 

'  6.  The  muscles,  on  the  other  hand,  by  their  con- 
traction, naturally  draw  the  head  of  the  bone  into  its 
place,  because  the  direction  of  their  fibres  is  such  as 
obliges  them  to  do  it.  The  great  art  of  managing 
luxations,  then,  consists,  in  ascertaining  cleai'ly  the 
obstacles  that  prevent  reduction,  in  removing  them, 
and,  then,  committing  the  rest  to  extension,  and  the 
powers  of  nature  properly  directed* 


MEMOIR  XII. 

«Kr    SPONTANEOUS     LUXATIONS-   OF    THE     OS 
FEMTORIS. 

1.  Our  modern  treatises  on  diseases  are  little  else 
than  fabrics  artfully  constructed  of  materials  confu- 
sedly scattered  through  the  writings  of  the  ancients.- 
Many  of  those  materials  oftentimes  esca^DC  our  no- 
tice, and  we  find  them  only,  after  practice  has  dis- 
closed them  to  us,  in  tlie  chambers  of  the  sick. 
Thus,  Hippocrates  had  an  accurate  knowledge  of 
spontaneous  luxations  of  the  os  femoris,  and  has 
even  left  an  aphorism  expressly  on  that  subject. 
Yet  this  disease  appeared  to  be  unknown  to  the 
physicians  who  came  after  him,  till  John  Louis  Petit, 
having  met  with  it  in  his  practice,  drew  the  attention 
of  practitioners  to  it,  by  a  memoir  respecting  it, 
published  among  those  of  the  Academy  of  Sciences, 
in  the  year  1722. 


300 

2.  The  history  of  this  affection,  which  wag  con- 
sidered afterwards,  ex  professo,  in  his  course  on 
diseases  of  the  bones,  has  been  sanctioned  by  the 
assent  of  all  practitioners,  to  whom  it  has  since  very 
frequently  occurred,  and  who  have  generally  admitted 
as  Louis  observes,  the  doctrine  of  Petit,  respecting 
the  cause  on  which  it  seems  to  depend, 

3.  Experience  bears  witness,  that  usually  a  fall 
on  the  great  trochanter,  more  rarely  on  the  knee, 
or  the  sole  of  the  foot,  precedes  it,  and  has  doubtless 
some  share  in  producing  it.  But  Avhat  is  the  nature 
of  the  primary  affection  which,  rising  immediately 
from  this  occasional  cause,  becomes  the  immediate 
cause  of  the  luxation  ?  Petit,  and  with  him  the  prac- 
titioners of  the  present  day,  have  conceived,  that  the 
different  parts  of  the  joint,  being  irritated  and  contu- 
sed, pour  out,  in  consequence  of  the  injury  received, 

a  superabundant  quantity  of  synovial  fluid,  which, 
not  being  absorbed  with  the  same  rapidity,  accumu- 
lates in  the  articular  cavity,  distends  the  capsule, 
and,  by  degrees,  forces  the  head  of  the  os  femoris 
from  its  natural  cavity.  Hence  astringent  and  tonic 
remedies,  with  alum,  spirit  of  wine,  &c.  are  di- 
rected to  be  applied  externally  to  the  upper  part  of 
the  diseased  thigh. 

4.  But  this  doctrine,  and  the  practice  which 
results  from  it,  seem  by  no  means  to  accord  with 
our  knowledge  of  anatomy.  The  truth  of  this  was 
deeply  impressed  on  the  mind  of  Desault,  who  had 
frequent  opportunities  of  witnessing  the  disease. 

Case  I.  A  young  woman  walking  hastily  along 
the  street,  slipped  and  made  a  false  step,  in  which 


301 

the  left  thigh,  being  violently  twisted,  supposed  for 
a  moment  the  whole  weight  of  the  body. 

A  severe  pain  experienced  at  the  moment,  obli- 
ged her  to  stop  at  first,  but  becoming  easier  after- 
wards, permitted  her  to  proceed  on  her  way,  and 
soon  ceased  entirely.  A  sensation  of  weight  occur- 
ring in  the  part  about  fifteen  days  afterwards,  was 
at  first  troublesome  to  the  patient  in  walking.  This 
sensation  was  afterwards  succeeded  by  a  dull,  deep- 
seated  pain,  accompanied  by  a  swelling  in  the  paits 
around  the  joint. 

During  six  or  seven  months  the  limb  was  obser- 
ved to  increase  in  length  gradually,  but  very  slowly. 
At  the  expiration  of  that  time,  a  contraction  took 
place  suddenly,  and,  in  one  night,  the  diseased  thigh 
became  shorter  than  the  other  by  nearly  two  inches. 
The  patient  was  then  admitted  into  the  hospital, 
where,  after  some  time,  she  sunk  under  her  disease. 
On  opening  the  body  the  following  appearances  were 
presented  to  Desault,  who  was  then  consulting  sur- 
geon to  the  institution. 

The  cartilage  of  the  acetabulum  swollen  to  such 
a  degree  as  to  fill  up  the  whole  extent  of  that  cavity, 
was  yellowish  and  inorganic,  somewhat  resembling 
bacon,  both  in  colour  and  consistence.  A  soft, 
spongy,  whitish  substance  projected  in  the  middle  of 
it,  the  remains  no  doubt  of  the  round  ligament.  The 
head  of  the  os  femoris,  situated  where  it  is  usually 
found  in  luxations  outward  and  upward,  was  sur- 
rounded by  a  cartilage  equally  tumefied. 

5.  Here  the  cause  of  the  displacement  of  the  os 
femoris  was  evident.  The  cartilages  becoming  tume- 


302 

£cd,  in  consequence  of  the  contusion  and  violence 
done  to  them,  had  by  degrees,  filled  up  the  acetabu- 
lum, forcing  out  in  the  same  gradual  manner  the 
head  of  the  bone.  Hence  arose  the  original  lengthen- 
ing of  the  limb.  But  as  soon  as  the  head  had  escaped 
from  the  lacerated  capsule,  the  limb  was  drawn  up- 
wards and  consequently  shortened,  by  the  action  of 
the  muscles,  and  the  weight  of  the  body  pushing  the 
pelvis  doAvnward. 

Case  II.  Some  years  afterwards,  Desault  had 
occasion  to  witness  again  the  same  disease,  in  the 
person  of  a  man  aged  thirty- seven,  who  put  himself 
under  his  care,  but,  being  obliged  to  leave  Paris,  a 
short  time  afterwards,  retired  into  the  country,  where 
he  died  in  about  six  months,  enfeebled  and  consumed 
by  a  hectic  fever. 

On  opening  the  body,  the  surgeon  of  the  place 
discovering  the  same  phenomenon  as  in  the  prece- 
ding case,  made  a  preparation  of  the  part,  and  sent  it 
to  Desault,  whose  pupil  he  had  been. 

6.  In  this  case  the  shortening  was  not  so  sudden 
as  in  the  preceding  one.  It  appeared  at  first  to  be 
coming  on,  during  five  days,  in  an  imperceptible 
manner,  \vhen,  fatigued  with  lying  in  bed,  and  hav- 
ing on  that  day  drank  a  little,  the  patient  attempted 
to  walk,  supported  only  by  a  cane.  By  evening,  a 
shortening  of  two  inches  and  a  half  had  taken  place, 
an  effect  evidently  produced  by  the  weight  of  the 
body  on  the  diseased  thigh.  Hence  the  necessity  of 
confining  the  patient  to  a  state  of  perfect  rest,  of  pre- 
venting, in  particular,  standing  and  walking,  and  all 
positions  in  which  the  diseased  thigh  would  have  to 
sustain  the  ^veight  of  the  body. 


303 

Case  III.  Maria  Genette  was  received  into  the 
Hotel-Dieu,  in  consequence  of  a  fall  on  the  great  tro- 
chanter. She  had  been  attacked  by  a  pain  in  the  joint 
of  the  thigh  of  tlie  same  side.  Walking,  which  was 
performed  with  difficulty,  augmented  the  pain,  and 
standing,  though  more  tolerable,  could  not  be  long 
continued.  The  thigh  was  evidently  longer  than  the 
other.  To  leave  the  disease  to  nature,  and  confine 
the  patient  to  a  state  of  rest,  constituted  the  practice 
of  Desault.  What  effect  could  the  external  use  of 
astringents,  recommended  by  Petit,  produce  in  such 
a  disease  ?  Some  time  after  her  admission,  the  patient 
was  attacked  by  dysentery,  in  consequence  of  which 
she  was  removed  to  the  medical  ward,  where  she 
died. 

On  opening  the  body,  the  paits  in  the  neighbour- 
hood of  the  joint  were  evidently  tumefied,  and  the 
capsule  was  stretched  from  above  downwards.  The 
head  of  the  os  femoris  was  situated  on  the  external 
edge  of  the  acetabulum.  The  capsule,  though  greatly 
elongated  was  stilt  in  a  state  of  tension ;  and  the  ar- 
ticular cartilage  was  swollen  to  such  a  degree,  as 
nearly  to  fill  up  the  cavity.  The  quantity  of  synovial 
fluid  was  less  than  natural. 

7,  This  case,  taken  at  a  period  of  the  disease  not 
fer  advanced,  fully  confirms  the  inference  deducible 
from  the  two  preceding  ones,  respecting  the  cause  of 
spontaneous  luxations.  Here,  indeed,  the  capsule 
not  having  given  way,  the  sv\eil3ng  having  only  just 
commenced,  and  the  synovia  existing  in  but  small 
quantity,  the  progress  of  nature  was  evident.  Here, 
also,  occurred  a  sign  not  noticed  by  Petit;  namely. 


304 

the  elongation  of  the  limb,  which  always,   in  such 
cases,  precedes  its  contraction. 

From  what  we  have  said,  it  appears,  1st,  that  the 
efficient  cause  of  spontaneous  luxations  of  the  os  fe- 
moris,  is  a  swelling  of  the  articular  cartilages,  which, 
alters  and  destroys  their  organization :  2dly,  that  the 
presence  of  this  swelling  must  necessarily  render 
fruitless  all  attempts  that  might  be  made  to  replace 
the  head  of  the  bone  in  its  cavity:  3dly,  that  the 
change  in  the  organization  of  the  cartilages,  renders 
astringents,  discutients,  and  other  external  means  ap- 
plied for  the  purpose  of  removing  the  tumefaction, 
entirely  useless :  4thly,  that  here,  as  in  many  other 
cases,  art  ought  to  confine  itself  to  the  palliation  of 
effects,  and  not  attempt  the  removal  of  causes. 


MEMOIR  XIII. 

ON  THE  FRACTURE  OF   THE  ROTULA. 

§1. 

1.  The  rotula,  a  sort  of  bony  production  of  tlie 
sesamoid  kind,  attached  to  the  tendon  common  to 
the  extensors  of  the  leg,  represents  a  moveable  pul- 
ley, intended  to  slide  on  that  formed  by  the  separation 
of  the  condyls  of  the  os  femoris.  It  protects  the  joint 
which  it  covers,  and,  in  point  of  structure,  use,  and 
situation,  greatly  resembles  the  olecranon,  from  which 
it  differs  only  in  this,  that,  instead  of  being  a  continu- 


ation  or  process  of  the  tibia  as  the  olecranon  Is  of  thcf 
ulna,  it  is  only  attached  to  that  bone  by  d  strong  atid 
thick  li^ment  which  is  inserted  into  its  tuberosit}^ 
Hence  it  follows,  that  betvveen  the  injuries  of  the  ond 
and  the  other,  there  must  be  a  great  analogy :  and  in- 
deed tno^t  of  the  signs  characteristic  of  fractures  of  thd 
olecr^oU,  are  characteristic  also  of  those  of  the  rdi 
tula,  and  the  treatment  which,  in  such  cases,  is  suit- 
able for  the  former,  diifets  but  little  from  that  required 
by  the  latter. 

OF    THE   VARIETIES   AND   CAUSES, 

2.  Fractures  of  the  rotula  may,  iii  gertefal,  as!- 
Sume  any  direction,  transverse,  IbngitudinaOi,  or  ob- 
lique: but  the  first  kind  occUrs  in  practice  much 
ftiore  frequently  than  the  others ;  and  so  gi'eat  indeedi 
is  the  disproportion,  that  it  has  almost  exclusively 
attracted  the  attention  of  authors,  in  the  iiumerotii 
forftis  of  apparatus  invented  to  retain  the  fragments. 

3.  A  shattering  of  the  bone,  the  effect  of  a  vio-' 
lent  blow;  a  contusion;  an  echymosis;  an  cffUsiofi 
of  blood  into  the  adjacent  soft  parts ;  one  or  tticitt 
wounds  of  the  soft  parts,  with  or  without  an  opening 
into  the  joint;  a  swelling,  the  degree  of  which  varies 
greatly,  according  to  the  state  of  the  fracture,  and  the 
disposition  of  the  subject,  but  which  is  constantly 
present;  a  double  division  of  the  bone,  one  of  which, 
being  longitudinal,  forms  an  angle  with  the  other, 
-T^hich  is  transverse;  and  a  concomitant  fracture  of 

the  cond^-^ls  of  the  os  femoris,  or  of  the  tibia :  such 

40 


306 

are  the  vaiieties  and  complications,  of  which  the  frac' 
ture  under  consideration  is  susceptible. 

4.  But  this  fracture  may  be  produced  in  two 
modes.  1st,  by  the  action  of  external  bodies:  2dly, 
by  tliat  of  the  extensor  muscles.  The  first  mode  of 
division  takes  place  in  falls  on  the  knee,  or  when  a 
body  in  motion  strikes  against  it,  and,  in  this  case, 
there  is  no  counter- stroke,  the  rotula  being  too  small 
for  such  an  occuiTcnce,  and  always  sustaining  the 
fracture  where  it  receives  the  blow.  In  the  second, 
the  fall  is  only  subsequent  to  the  fracture,  and,  as 
Camper  has  well  observed,  is  most  frequently  the 
effect  of  it.  For  instance,  the  line  of  gravity  of  the 
body  is,  by  some  cause,  removed  behind  it;  the  an- 
terior muscles  contract  themselves  to  bring  it  forward 
again;  the  extensors  act  on  the  rotula;  it  is  bro- 
ken, and  a  fall  ensues.  Again,  the  leg  is  suddenly 
thrown  into  a  state  of  violent  extension;  the  exten- 
sors act  w  ith  great  force ;  a  fi-acture  is  the  conse- 
quence, and  the  patient  falls.  A  soldier  once  fi-actur- 
ed  his  rotula  in  kicking  at  his  serjeant;  thus  the  ole- 
cranon, in  like  manner,  has  been  broken  by  throwing 
a  stone.  A  man,  in  the  Hotel-Dieu,  fractured  the 
rotula  of  each  knee,  in  the  operating  room,  by  means 
of  convulsive  motions,  produced  by  the  operation  of 
lithotomy. 

5.  The  action  of  external  bodies,  can  alone  pro- 
duce a  longitudinal  fracture,  as  when  a  person  falls  on 
a  sharp  projecting  piece  of  timber :  but  this  may  also 
produce  a  transverse  fracture.  On  the  other  hand, 
muscular  action  can  never  give  rise  to  any  but  the 
latter  kind,  since  the  direction  of  this  fracture  is  at  a 


307 

right  angle  with  that  of  the  extensors.  A  fracture 
resulting  from  the  action  of  external  bodies,  is  often- 
times accompanied  by  a  wound,  a  contusion,  or  a 
shattering  of  the  part  (2) ;  a  fracture,  arising  from 
muscular  action,  is  always  simple,  except  as  to  a 
swelling  around  the  joint.  The  latter  cause  may, 
instead  of  fracturing  the  rotula,  rupture  the  common 
tendon  of  the  muscles,  or,  what  is  more  common,  the 
inferior  ligament.  Desault  has  seen  many  examples 
of  this :  Petit  has  also  observed  several,  and  Sabatier 
has  sometimes  met  with  them.  External  violence 
seldom  produces  this  double  accident. 

HII. 

OF   THE    SIGNS   AND    THE    DISPLACEMENT. 

6.  In  longitudinal  fractures  the  diagnosis  is  always 
accompanied  with  more  or  less  difficulty,  because  the 
extensor  muscles,  drawing  by  their  contractions  the 
two  fragments  equally  upwards,  and  the  inferior  liga- 
ment holding  them  equally  down,  tend  to  keep  them 
in  apposition,  and  to  prevent  them  from  separating. 
Sometimes  also  the  ligamentous  production  which 
covers  the  rotula,  remains  entire  and  serves  to  keep 
the  fragments  together.  It  will  be  necessary,  there- 
fore, should  the  existence  of  such  a  fracture  be  sus- 
pected, to  move  the  two  sides  of  the  rotula  in  oppo- 
site directions,  by  pressing  them  to  the  right  and  to 
the  left,  in  order  to  arrive  at  certainty  on  the  subject. 
Should  a  wound  exist,  as  is  oftentimes  the  case  (5) 
the  diagnosis  is  less  difficult. 


50$ 

7.  If  the  diyisipii  be  transverse,  the  diagnosis  be- 
comes then  as  plain  and  easy,  as  it  is  difficult  and 
obscure  in  cases  where  it  is  longitudinal.  In  such  a 
case,  a  considerable  separation  or  space  exists  he-. 
tween  the  twp  fragments,  sensible  to  the  touch,  w^en 
the  hand  is  placed  on  the  knee.  In  this  separation, 
the  fragments  are  not  displaced  by  the  same  mean?. 
The  superior  fragment  being  attached  to  the  exten- 
sors, is  drawn  upwards  with  great  force  by  these 
muscles,  the  action  of  which  the  rotula  no  longer 
resists.  The  lower  fragment,  on  the  other  hand, 
being  attached  only  to  the  inferior  ligament,  is  not 
moved  by  any  muscle,  and  cannot  be  displaced  in 
any  other  way  than  by  the  motions  of  the  leg  with 
which  it  is  still  connected. 

8.  Hence  it  follows,  1st,  that,  in  a  state  of  exten- 
sion, the  separation  is  the  least  possible,  because  it 
is  tlien  produced  on  the  part  of  the  superjior  fragment 
only;  2dly,  that  in  a  state  of  flexion  it  is  greatest, 
because  then  both  fragments  conciir  alike  in  produ- 
cing it ;  3dly,  that  it  may  be  increq.sed  or  diminishe^^ 
by  vaiying  the  degrees  of  flexion. 

9.  This  fracture  is  further  characterized  by  the 
following  circumstances,  namely,  a  practicability  of 
moving  the  fragments  transversely  in  opposite  dir 
rections,  and  of  producing,  by  that  means,  some 
degree  of  crepitation,  provided  they  be  first  brought 
close  together;  by  tl^e  pain  vdiich  accompanies  these 
motions;  by  the  swelling  common  to  every  kind  of 
fracture  of  the  rotula,  and  which,  if  yery  great,  may 
involve  tlie  other  signs  in  more  or  less  uncertainty ; 
by  a  difficulty  of  standing;  and  an  almost  entire  loss 


309 

of  the  power  of  walking,  in  consequence  of  the  e^c- 
Jensors  being  no  longer  able  to  coiiimunicate  motion 
to  the  leg,  unless  when  the  fracture  exists  vejy  low 
(iown,  near  to  the  inferior  ligament. 

10.  The  touch  v/ill  always  discover  in  what  part 
of  the  bone  the  fracture  is  situated,  which,  if  it  be 
oblique,  will  partake  more  or  less  of  the  characters  of 
the  longitudinal  or  the  transverse,  accox'dingly  as  it 
approaches  to  the  one  or  the  other. 

§  IV. 

OF    THE    PROGNOSIS. 

11.  Many  authors  have  pretended  that  fractures 
of  the  rotula  cannot  be  cured,  and  it  even  appears 
that  the  Academy  of  Surgery  adopted  this  opinion, 
on  receiving  a  memoir  from  a  Flemish  physician, 
which  contained  several  facts  tending  to  establish 
that  principle.  But  what  do  these  facts  prove?  That 
in  some  particular  cases,  reunion  did  not  take  place, 
but  they  do  not  show  that  this  w^as  owing  to  the  na- 
ture of  the  fracture. 

12.  But,  what,  in  such  cases,  could  prevent  a 
cure  from  taking  place?  The  structure  of  the  ro- 
tula differs,  say  they,  from  that  of  the  other  bones. 
Now,  admitting  this  difference  of  structure  to  be 
j^eal,  it  certainly  approaches  to  the  structure  of  tendons 
to  which  indeed  it  bears  a  strong  affinity.  But,  who 
does  not  know,  that,  when  tendons  are  divided,  they 
lanjte  ^s  readily  as  bones?  Besides,  is  not  the  power 
of  reunion  common  to  every  part  endowed  with  life? 
I  have  already  shown,  when  treating  of  other  frac- 


310 

turcs  that  communicate  with  joints,  what  credit  is 
due  to  those  hypotheses  so  often  revived  but  never 
confirmed,  nay  even  clearly  proved  to  be  unfounded, 
such  as,  an  effusion  of  callus  into  the  joint,  a  failure 
of  reunion  from  a  w^ant  of  periosteum  on  the  poste- 
rior part  of  the  bone,  the  synovia  diluting  the  mat- 
ter of  callus,  and  thus  preventing  it  from  being  duly 
prepared,  &c. 

13.  The  inflammation  of  the  articulating  sur- 
faces and  of  the  ligaments  around  the  joint,  ought  to 
have  more  influence  in  constituting  an  unfavourable 
prognosis,  than  any  circumstance  that  authors  have 
mentioned.  But  experience  proves,  that,  when  judi- 
ciously treated,  these  fractures  are  not  accompanied 
by  that  accident,  and  even  that  the  swelling,  which 
for  the  most  part  attends  them,  always  yields  more 
or  less  speedily,  when  a  bandage,  uniformly  applied, 
presses  equally  on  all  parts  around  the  joint,  and  thus 
forms  a  kind  of  discutient,  while  at  the  same  time 
it  retains  the  fragments. 

14.  Pare,  Fabricius  of  Hilden,  and  a  number  of 
other  wTiters,  have  pretended,  that  some  degree  of 
lameness  must  always  be  the  consequence  of  this 
fracture.  But,  from  what  causes  must  this  lameness 
So  certainly  arise?  Is  it  from  a  want  of  reunion  in 
tihe  part?  I  have  already  shown  (11  and  12)  that  this 
apprehension  is  wholly  unfounded.  Is  it  from  an  an- 
chylosis? This  accident  cannot  take  place,  except 
either  in  consequence  of  inflammation  occurring  in 
the  articulating  surfaces,  (and  I  have  already  shown 
how  that  may  be  avoided,  13)  or  of  a  stiffiiess  in  the 
ligaments,  and  I  shall  hereafter  make  it  appear  that 


311 

that  may  be  readily  pi^eyented  by  motion.  Is  it  from 
the  fragments  being  drawn  asunder,  and  in  that  state 
united  by  an  intermediate  substance  of  too  great  an 
extent?  I  shall  prove,  that  a  bandage  properly  con- 
structed, is  always  sufficient  to  keep  these  fragments 
in  contact. 

From  these  considerations  it  appears,  that  writers 
have,  in  general,  without  sufficient  cause,  given  an 
unfavourable  prognosis,  in  relation  to  fractures  of  the 
rotula,  which  have,  indeed,  a  great  affinity  to  other 
affections  of  the  same  kind. 

i«F  THE   REDUCTION    AND   THE   MEANS  OF  MAIN- 
TAINING   IT. 

15.  I  have  already  observed  (7),  that  the  causes 
of  the  separation  of  the  fragments  are,  as  far  as  respects 
the  upper  one,  the  contraction  of  the  extensor  mus- 
cles; and,  in  relation  to  the  lower  one,  the  flexion  of 
the  leg;  whence  it  follows,  that  the  means  of  pre- 
serving contact  between  these  fragments  are  1st,  all 
those  that  are  calculated  for  the  prevention  of  mus- 
cular action;  2dly,  such  as  may  keep  the  limb  in  a 
state  of  permanent  extension.  Hence  two  leading 
curative  indications  must  be  fulfilled  by  the  bandage 
constructed  for  fractures  of  the  rotula:  the  last  of 
these  indications  presents  in  general  but  little  diffi- 
culty; but,  with  regard  to  the  other,  the  case  is 
different.  To  fulfil  the  latter,  it  is  necessary  first, 
to  weaken  the  contractile  force  of  the  muscles,  and 
by  that  means  diminish  the  effort  wMch  they  make 


M2 

to  draw  the  superior  fragment  upwards;  aiid  then," 
to  oppose  to  them  a  proper  mechanical  resistance,* 
which,  by  acting  in  a  direction  the  very  reverse  of 
that  in  which  they  act,  may  counitervail  their  efforts. 

16.  But  the  force  of  contraction  is  dimihished,  1st, 
by  tliro\^dng  the  muscular  fibres  into  a  state  of  relaxa- 
tion; this  end  is  best  attained  by  bending  the  thigh  on 
the  pelvis :  2dly,  by  making  compression  bver  th^ 
whole  limb,  by  means  of  a  circular  bandage,  Which, 
by  confining  the  muscles,  tends  to  restrain  and  weak- 
en their  action.  Thus  it  is  kno^vn  that  the  advantage 
of  the  bandage  employed  to  unite  transverse  wounds, 
consists  chiefly  in  that  compression  wliich,  by  dimi- 
nishing muscular  action,  prevents  the  retraction  of 
their  edges.  Another  advantage  resulting  fi-om  the 
bandage  in  this  case  is,  that  it  prevents  the  swelling 
of  the  limb. 

17.  As  to  the  mechanical  resistance,  which  must 
act  in  a  direction  opposite  to  that  of  the  contraction 
of  the  muscles,  and,  by  that  means,  prevent  the  dis- 
placement of  the  superior  fragment,  it  cannot,  in  the 
present  case,  be  of  the  same  nature  as  in  fractures  of 
the  thigh,  the  clavicle,  &:c.  where  permanent  exten- 
sion is  practised.  The  superior  fragment  offers  too 
small  a  purchase  for  any  extending  forces  to  act  on. 
This  resistance  must  be  made,  then,  by  placing  some 
body  above  this  fragment,  and  retaining  it  in  that 
situation  with  a  force  sufficient  to  hinder  the  fragment 
fi'om  rising  upwards :  such  as  a  few  turns  of  a  roller 
drawai  tight,  a  bit  of  leather,  some  hollow  com- 
presses, &c. 


5U 

18.  It  is  evident  from  the  foregoing  principles, 
that  every  bandage  intended  to  retain  a  transverse 
fracture  of  the  rotula,  ought  to  be  calculated  to  main- 
tain the  following  state  of  things:  1st,  the  extension 
of  the  leg  on  the  thigh;  2dly,  the  flexion  of  the  thigh 
on  the  pelvis;  3dly,  a  uniform  compression  over  the 
whole  limb ;  and,  4thly,  some  mechanical  resistance 
properly  secured  above  the  superior  fragment:  the 
three  last  expedients  relate  to  the  displacement  of  that 
fragment  alone ;  while  the  first  has  a  relation  to  that 
of  the  lower  one.  Let  us  examine  whether  or  not  the 
bandages,  hitherto  employed  by  different  authors,  be 
calculated  for  these  purposes. 

19.  M.  Valentin,  believing  that  position  alone 
was  sufficient  to  retain  the  fragments  in  contact,  ne- 
glected the  application  of  apparatus  entirely,  which 
he  even  considered  as  hurtful,  in  consequence  of  the 
swellmg  it  produced ;  but  experience  soon  proved 
the  insufficiency  of  this  method.  The  slightest  move- 
ment, or  the  least  effort  on  the  part  of  the  patient, 
made  the  extensor  muscles  contract,  which,  drawing 
the  superior  fragment  upwards,  separated  it  from  the 
lower  one ;  and,  as  the  time  of  reunion  is  in  direct 
proportion  to  the  distance  of  the  fragments  from  each 
other,  it  must,  under  such  treatment,  have  been 
necessarily  tedious,  and  soriietimes  must  have  even 
failed  altogether. 

20.  As  to  a  swelling  being  produced  by  the  ban- 
dage, this  never  occurs,  unless  when  some  openings 
are  left,  through  which  the  integuments  protruding 
become  tumefied :  but,  when  the  pressure  is  uniform 
throughout,  when  the  fluids  find  throughout  an  equal 

41 


314 

tesistance,  this  accident  is  not  to  be  apprehended,  as 
is  proved  by  the  practice  of  Desault,  who  never  met 
with  it;  on  the  contrary,  a  bandage  properly  con- 
structed and  applied,  is  calculated  to  prevent  swell- 
ing (16). 

Mere  position,  then,  though  always  of  service  in 
this  affection,  is  not  alone  sufficient,  because  it  fulfils 
only  the  first  of  the  indications  or  principles  laid  down 
with  respect  to  every  form  of  apparatus  for  transverse 
fractures  (18),  namely,  that  which  relates  only  to  the 
lower  fi-agment;  while  those  that  relate  to  the  upper 
one,  remain  still  to  be  fulfilled. 

21.  Most  authors  have  employed,  with  a  view  ta 
these,  a  kind  of  figure  of  8  bandage,  known  in  art  by 
the  name  of  Kiastre^'^  and  approved  of  by  Petit, 
Heister,  Sicc.  This  is  made  of  a  roller  formed  into- 
two  balls,  which  are  brought  across  each  other  alter- 
nately under  the  ham,  passing  over  two  hollow  or 
forked  compresses  ^  tliat  enclose  the  two  fragments  of 
the  rotula. 

But  the  unequal  pressure  which  this  makes  on 
the  unequally  projecting  parts  of  the  knee,  renders 
its  application  ex:tremely  painful,  particularly  below, 
where  the  pasteboard  covering  applied  by  Louis,  im- 
mediately on  the  skin,  afforded  but  a  feeble  protec- 
tion to  the  tendons  of  the  flexors.  Besides,  it  did  not 
prevent  the  swelling,  which  is  indeed  a  necessary 
consequence  both  of  this  unequal  pressure,  and  of 
the  openings  left  between  the  casts  of  the  bandage. 
This  swelling  is  taken  notice  of  by  all  writers,,  and 
is,  according  to  them,  one  of  the  troublesome  cir- 

*  I  know  not  of  any  English  tenn  equivalent  to  this.    T- 


315 

cumstances  attending ,  the  fracture.   The  third  indi- 
cation is  not  ail  fulfilled  (18), 

22.  The  extensor  muscles,  not  being  at  all  com- 
pressed, will  act  widi  their  whole  force  on  the  upper 
fragment,  and,  on  the  slightest  effort  of  the  patient, 
overcome  the  resistance  of  the  bandage,  the  action  of 
which,  being  oblique  with  respect  to  the  fragment, 
is  inconsiderable,  unless  it  be  drawn  very  tight,  and 
thus  a  displacement  will  again  occur.  This  obliquity 
of  the  turns  of  the  roller  obliges  the  surgeon,  either 
to  draw  it  very  tight,  in  which  case  a  swelling  is  in- 
evitable, or  to  make  it  but  moderately  tight,  and  then 
the  apparatus  will  be  insufficient  to  resist  the  action 
of  the  muscles. 

23.  Most  of  the  objections  to  the  ancient  appara- 
tus for  fractures  of  the  rotula,  apply  also  both  to  that 
proposed  by  Ravaton  in  his  surgery,  and  to  that 
which  Bell  employs  in  his  practice.  Both  of  these, 
while  they  fail  in  making  sufficient  resistance  to  mus- 
cular action,  as  well  as  in  fulfilling  the  third  conditijor^ 
laid  down  as  necessary  to  every  bandage  (18),  contri- 
bute to  the  swelling,  and  can  rarely  produce  a  perfect 
contact  between  the  fragments.  Thus  Bell  has  well 
observed,  that  tiie  reuniqn  is  rarely  perfect,  and  that 
there  is  always  a  separation  more  or  less  perceptible. 

24.  The  complication,  the-iiitricacy,  the  expense,^ 
and  other  more  weighty  inconveniences  of  the  ma- 
chine described  by  Garengeot  in  his  treatise  on  in- 
struments, and  employed,  for  the  first  time,  by 
Arnaud,  and  also  of  that  which  was  proposed  and 
used  by  Solingen,  have,  long  since,  entirely  banished 
them  from  among  the  means  of  reduction. 


516 

0 

25.  Some  practitioners  have  advised  the  uniting 
bandage  used  in  cases  of  transverse  wounds,  which  is 
formed,  as  is  well  known,  of  two  small  rollers  or 
strips  placed  in  the  longitudinal  direction  of  the  limb, 
one  of  them  having  holes  in  it,  to  w^hich  the  divisions 
of  the  other  are  fastened.  Both  of  these  are  first 
secured  by  circular  turns;  being  then  dra^vn  in  op- 
posite directions  so  as  to  meet,  they  draw  the  parts 
on  \vhich  they  are  applied  in  the  same  directions* 
But  the  action  of  tliis  bandage  is  confined  to  the  inte- 
guments, and  would  have  of  course  but  a  feeble 
influence  on  the  fragments  beneath.  It  is  also  attend* 
ed  with  this  further  inconvenience,  that  by  wrinkling 
the  integuments,  and  tin  owing  them  into  folds,  it 
might  press  them  dowii  between  the  fragments,  and 
thus  prevent  their  contact.  Besides,  it  is  liable  to  most 
of  the  objections  urged  against  the  preceding  one. 

26.  This  view  of  the  means  employed  by  different 
practitioners,  to  counteract  the  causes  of  displacement 
in  this  fracture,  are  sufficient  to  convince  us,  that  the 
difficulties  hitherto  experienced  in  the  treatment  of  it, 
have  arisen  from  the  feebleness  of  the  former,  and  the 
strength  of  the  latter.  So  great  indeed  have  been 
these  difficulties,  that  some  authors,  conceiving  a  re- 
union impossible,  have,  in  conformity  to  such  an 
opinion,  though  contrary  to  all  the  rules  and  principles 
of  the  profession,  advised  us  to  abandon  the  patient  to 
himself.  But  I  have  already  exposed  the  fallacy  of 
that  opinion,  respecting  the  Vv^ant  of  a  healing  power 
in  the  rotula  (12),  an  opinion  which,  if  generally 
adopted,  w'ould  give  rise  to  consequences  of  the  most 
serious  nature.    In  the  present  case,  as  in  all  other 


^17 

fractures,  the  contact  of  the  fragments  ought  to  be  the 
chief  object  of  the  surgeon's  efforts. 

27.  But  ought  this  contact  to  be  perfect  and  exact? 
Several  authors,  particularly  Bell,  have  conceived, 
that  the  motions  of  the  limb  can  be  performed  as  well 
with  a  slight  separation  of  the  fragments.  Pott  even 
declares  that  such  a  separation  will  enable  the  patient, 
after  his  recovery,  to  walk  with  more  ease.  Flajani 
advances  the  same  opinion  in  a  dissertation  on  the 
subject. 

From  this  doctrine  arose  a  new  mode  of  treatment, 
which  consisted  in  not  suffering  the  fragments  to  be 
at  rest.  They  were  accordingly,  during  the  cure,  put 
frequently  in  motion,  the  more  effectually  to  prevent 
an  anchylosis,  which  is  sometimes  the  consequence 
of  this  fracture. 

28.  But,  on  the  one  hand,  it  is  difficult  to  con- 
ceive, on  what  this  opinion  of  these  authors  can  be 
founded;  while,  on  the  other,  reason  declares,  in  the 
plainest  and  most  forcible  terms,  that  the  more  the 
state  of  a  bone,  after  it  has  been  broken,  differs  from 
its  natural  state,  the  less  fi'ee  will  be  the  exercise  of 
its  functions,  and,  that  the  perfection  of  the  treatment 
of  fractures  consists,  in  leaving  behind  it  no  vestige 
of  the  accident. 

29.  This  truth  was  frequently  confirmed  in  the 
experience  of  Desault,  who  had  an  opportunity  of 
seeing  numerous  fractures  of  the  rotula,  both  in  the 
Hotel-Dieu,  and  in  his  private  practice.  He  always 
observed,  that,  when  the  separation  of  the  fragments 
was  considerable,  and  the  ligamento- cartilaginous 
substance  uniting  them  was  of  some  extent,  standing 


318 

and  walking  were  performed  with  much  difficulty; 
that  the  patient  was  exposed  to  frequent  falls,  from 
the  want  of  a  proper  coiTespondence,  in  point  of 
strength  and  motion,  between  the  two  limbs;  and 
that,  on  the  contrary,  the  kss  extensive  the  separa- 
tion and  the  substance  that  filled  it  up  were,  the 
more  free  and  easy  were  the  motions  of  the  part, 
which  still  remained,  however,  somewhat  defective  and 
imperfect,  unless  every  vestige  of  the  division  was 
obliterated, 

Paul  of  Egina  long  since  observed,  that,  when 
no  means  of  reduction  were  employed,  though  the 
patient  might  walk  tolerably  well  on  a  level  surface, 
lie  could  not,  without  difficulty  go  up  an  ascent. 

30.  From  what  has  been  said,  it  follows,  1st, 
that  in  the  treatment  of  this  fracture,  the  perfect 
contact  of  the  fragments  ought  to  be  the  principal 
object  of  the  practitioner;  2dly,  that  the  kinds  of 
apparatus  employed  by  different  authors,  are  but  ill 
calculated  for  the  attainment  of  this  end,  because  they 
fulfil  but  imperfectly  the  indications  formerly  laid 
down  (18),  Let  us  see  whether  or  not  the  appara- 
tus of  Desault  be  any  better  suited  to  this  purpose. 

31.  The  bandage,  wliich  he  employed  in  this 
case,  analogous  to  that  for  fractures  of  tlie  olecranon, 
is  composed,  1st,  of  one  spUnt,  two  inches  broad, 
and  long  enough  to  reach  from  the  tuberosity  of  the 
ischium,  to  a  little  above  the  heel;  2dly,  of  two 
roUers,  five  or  six  yards  long,  and  neaily  three  inches 
wide;  3dly,  of  another  single  roller,  with  two  holes 
about  the  middle  of  it,  a  little  longer  than  the  injured 
lim.b  of  the  patient,  along  the  fore  part  of  which  it 
must  be  extended. 


319 

32.  Every  thing  being  arranged  for  the  applica- 
tion of  the  apparatus, 

1st,  One  assistant  secures  the  pelvis,  in  the 
same  manner  as  in  fractures  of  the  lower  extremities; 
while  another  keeps  the  leg  in  a  state  of  perfect  ex- 
tension on  the  thigh,  and  the  thigh  on  the  pelvis. 

2dly,  The  surgeon,  then,  standing  by  the  side 
of  the  fractured  limb,  extends  along  the  anterior  part 
of  the  leg  and  thigh  the  roller  with  holes  in  it,  having 
previously  wet  it  with  vegeto- mineral  water,  taking 
care  to  make  the  two  openings  correspond  to  the 
lateral  parts  of  the  rotula,  that,  by  being  thus  better 
adapted  to  its  shape,  it  may  not  be  thrown  into 
wrinkles. 

3dly,  He  then  secures  it  on  the  t€^  of  the  foot, 
by  three  circular  casts  of  a  roller  placed  one  over 
the  other,  three  or  four  inches  above  its  lower  end 
which  must  next  be  turned  up  over  the  three  first 
casts,  and  made  fast  by  two  other  ones.  Then, 
while  the  compress  roller*  is  secured  above  by  aa 
assistant,  he  passes  up  along  the  leg  by  oblique  and 
reverse  turns,  according  to  the  inequalities  of  the 
limb. 

4thly.  Having  arrived  at  the  lower  part  of  tl^ 
knee,  he  pushes  the  lower  fragment  upwards,  and 
makes  below  it  two  or  three  circular  turns  to  secure 
it.  He  then  gives  the  roller  into  the  hands  of  an, 
assistant,  and  directing  him  who  holds  the  long  com- 
press roller,  to  draw  it  forcibly  upwards,  pushes  the 

*  The  roller  or  strip  with  holes  in  it,  which  is  extended 
along  the  fore  part  of  the  limb,  serving,  in  some  measure,  the 
purpose  of  %  compress.  Trans. 


^  320 

integuments  of  the  knee  in  the  same  direction,  lest, 
by  becoming  interposed  between  the  fragments,  they 
might  prove  an  obstacle  to  their  reunion.  Passing 
then  the  fingers  of  his  left  hand  through  the  holes  in 
the  compress-roller  he  places  them  behind  the  supe- 
rior fragment  and  pushes  it  forcibly  do^vnwards. 

5thly,  When  the  reunion  of  the  fragments  is 
exact,  without  any  space  intervening,  he  resumes 
the  roller,  and  passing  it  obliquely  under  the  ham, 
and  bringing  it  up  again  behind  the  superior  frag- 
ment, withdraws  his  fingers  which  held  this  fragment 
down.  In  place  of  his  fingers,  he  then  apphes  two  or 
three  tight  circular  casts,  covers  the  knee  with  seve- 
ral oblique  casts  in  form  of  the  figure  of  8,  so  as  to 
leave  no  opening  between  them,  and,  then,  continues 
the  bandage  up  along  the  thigh,  securing  by  it  the 
compress-roller  extended  along  the  fore  part  of  the 
limb. 

6thly,  When  he  has  arrived  at  the  upper  part 
of  the  limb,  the  assistant  who  holds  the  compress- 
roller,  drawing  it  forcibly  upwards,  doubles  down  its 
end  over  the  circular  casts.  The  surgeon  next  fix- 
ing this  end  by  several  additional  casts,  descends 
again  along  the  thigh,  covers  the  knee  by  a  few 
more  oblique  turns,  and  finishes  with  the  roller  on 
the  leg. 

33.  This  first  part  of  the  bandage  evidently  fulfils 
the  third  and  fourth  indications  (18).  The  compres- 
sion of  the  roller  on  the  muscles  weakening  their 
action  and  impeding  their  motions  prevents  their 
tendency  to  draw  the  superior  fragment  upwards; 
while  the  circular  casts  passed  behind  this  fragment, 


321 

acting  in  opposition  to  the  muscular  contractions, 
pre^^ents  it  from  moving  upwards  in  obedience  to 
them.  The  long  compress-roller,  stretched  on  the 
fore  part  of  the  limb,  being  first  secured  below,  and 
then  drawn  forcibly  upwards,  presses  the  casts  of 
the  roller  against  each  other,  and  prevents  those  that 
correspond  to  the  thigh  from  slipping  upwards,  and 
thus  abandoning  the  superior  fragment,  and  prevents 
also  those  on  the  leg  from  slipping  down  and  with- 
drawing their  support  from  the  inferior  fragment.  As 
there  remains  no  vacant  space  between  the  circular 
turns,  their  pressure  is  uniform  throughout:  no 
swelling  can  consequently  supervene  (20). 

34.  But  the  first  and  second  indications  remain 
still  to  be  fulfilled  (18):  it  is  necessar}^  to  prevent  the 
separation  of  the  lower  fragment,  by  the  extension  of 
the  leg  on  the  thigh,  and  to  throw  the  muscles  into 
a  state  of  relaxation  by  extending  the  thigh  on  the 
pelvis,  and  to  maintain  permanently,  by  the  appara- 
tus, that  double  position,  which  the  assistant  main- 
tains only  during  the  operation. 

35.  To  obtain  the  first  effect  different  means  have 
been  employed;  but  none  answers  so  well,  to  extend 
the  limb  and  retain  it  immoveably  in  tliat  state,  as  a 
long  and  strong  splint,  placed,  as  Desault  did  it,  sub- 
sequently to  the  application  of  die  first  part  of  the 
bandage,  along  the  posterior  part  of  the  limb.  An 
assistant  must  hold  the  end  of  this  splint,  while  the 
surgeon  secures  it  in  its  place- by  the  second  roller 
(31):  in  this  way  the  extension  of  the  leg  is  effected. 

36.  To  obtain  the  extension  of  the  thigh,  it  is 
necessary  to  place  on  the  top  of  each  other,  two  or 

42 


322 

three  bolsters  or  little  bags  filled  with  chaff,  so  dis- 
posed as  to  form  an  inclined  plain,  considerably  ele- 
vated towards  the  heel  above  the  level  of  the  bed, 
but  which,  gradually  descending  to  the  same  level 
towards  the  tuberosity  of  the  ischium,  forms  a  sup- 
porting basis  on  which  the  whole  limb  may  rest  in  a 
uniform  manner.  By  this  twofold  extension  of  the  leg 
and  of  the  thigh,  the  lower  fragment  is  kept  up  im- 
moveably,  and  the  muscles  are  kept  in  a  state  of 
relaxation. 

Hence  it  follows,  that  this  bandage  fulfils  ex- 
tremely well  the  conditions  laid  down  (18),  and  that 
it  ought  to  be  preferred  to  all  the  others  (19.... 2 5), 
which  answered  the  indications  only  in  part. 

37.  Whatever  may  be  the  advantages  of  this  ban- 
dage over  the  others,  it  m.ust  still  be  acknowledged 
to  have  its  inconveniences.  The  rollers  become  re- 
laxed in  a  short  time ;  their  compression  is  less  active ; 
the  muscles,  being  less  confined,  contract  more  rea- 
dily ;  hence  the  necessity  of  frequently  repeating  the 
application  of  the  apparatus,  a  circumstance  which  is 
very  troublesome,  on  account  of  the  roller  which 
composes  it,  and  covers  the  whole  limb.  The  resist- 
ance of  it  even  when  it  is  recently  applied,  is  not 
always  equal  to  the  power  of  the  muscles,  whence 
the  most  assiduous  attention  is  necessary,  to  obtain 
such  a  consolidation  as  to  leave  no  trace  of  the  frac- 
ture behind.  Few  persons  ever  possessed,  like  De- 
sauit,  the  art  of  overlooking  nothing  that  might  in 
any  way  contribute  to  the  success  of  his  treatment: 
from  this,  no  less  than  from  the  excellence  of  his  pro- 
cesses, arose  the  number  of  his  cures.  Let  us  con- 


323 

firm,  by  a  few  examples  selected  from  among  a  great 
many,  the  doctrine  here  laid  down.  The  following 
cases  were  collected  by  Julian  and  Bezard. 

Case  I.  Francis  Leclert,  of  a  sanguine  tempera- 
ment, fell  on  the  7th  of  October,  1790,  on  his  right 
knee,  and  produced  a  transverse  fracture  of  the 
rotula.  He  was  not  able  to  rise ;  he  was  carried 
home,  where  a  surgeon,  on  discovering  the  nature  of 
his  disease,  advised  him  to  be  taken  to  the  Hotel- 
Dieu. 

He  was  conveyed  thither  on  the  day  following, 
and,  in  the  interval,  a  considerable  swelling  had  oc- 
curred around  the  joint.  The  usual  bandage  was 
employed ;  the  pains  ceased  immediately  after  its  ap- 
plication; a  copious  blood-letting  was  directed,  and 
a  low  diet  was  prescribed. 

The  whole  apparatus  was  wet  with  vegeto- mine- 
ral water,  two  or  three  times  a  day.  On  the  next  day 
some  light  food  was  allowed,  and  the  quantity  in- 
creased by  degrees,  till  in  a  short  time  the  patient 
returned  to  his  usual  regimen.  Eighth  day,  the 
swelling  being  almost  gone,  the  bandage  had  become 
relaxed  it  was  therefore  reapplied.  Every  day  the 
inclined  plain  formed  by  the  bolsters  was  carefully 
examined,  and  put  in  order  again  as  often  as  it  be- 
came deransred. 

Fifteenth  day,  a  new  application  of  the  apparatus : 
twentieth  day,  an  evacuation  in  consequence  of  a 
bilious  disposition.  Nothing  particular  occurred  from 
this  time  till  the  completion  of  the  cure,  which  took 
place  on  the  sixty -seventh  day  after  the  accident:  no 
depression  existed  at  the  place  of  the  fracture :  the 


524 

motions  were  perfectly  freej  these  were  aided,  by 
daily  exercising  the  knee  joint  for  some  time. 

Case  IL  Vincent  Grenier,  aged  thirty-eight, 
making  a  false  step,  fell  on  the  rotula,  and  fractured 
it,  on  the  6th  of  June,  1791 :  he  was  brought  to  the 
Hotel-Dieu,  where  Desault  demonstrated  to  his  pu- 
pils, by  the  usual  signs  the  existence  of  the  disease : 
a  considerable  swelling  had  already  taken  place.  The 
bandage  formerly  described  was  applied:  the  same 
precaution  as  in  the  preceding  case ;  apparatus  ex- 
amined every  dayj  renewed  as  often  as  relaxed; 
extension  maintained  with  great  exactness.  On  the 
forty -fifth  day,  the  consolidation  was  nearly  effected ; 
on  the  fifty-second  it  was  complete,  the  joint  was 
exercised  for  some  time,  and  on  the  seventy-serenth 
day  the  cure  being  in  all  respects  complete,  the  pa- 
tient was  discharged. 


325 


MEMOIR  XIV. 

ON  THE  FORMATION   OF  FOREIGN   BODIES  IN 
THE  JOINT  OF   THE  KNEE. 

1.  The  history  of  foreign  bodies  divides  itself 
naturally  into  two  great  sections;  the  one  includes 
those  that  are  introduced  from  without;  the  other 
such  as  are  formed  within  our  own  systems.  This 
latter  section  maybe  again  divided  into  two  classes;  to 
the  first  class  belong  bodies  altogether  inorganic,  such 
as  the  difierent  kinds  of  stones;  to  the  second,  those 
which  are  truly  organic,  and  become  foreign  only  by 
being  situated  in  places  where  they  impede  the  func- 
tions, such  as  cartilaginous  or  bony  productions, 
existing  accidentally  within  the  joints. 

On  the  subject  of  the  latter  class,  art  is  much  more 
deficient  than  she  is  with  regard  to  the  former.  Let 
us  endeavour  to  assist  her  a  little,  by  giving  a  sketch 
of  the  opinions  and  practice  of  Desault  with  respect 
to  these  productions. 

2.  Before  his  time,  the  surgery  erf  France  appears 
to  have  contained  scarcely  a  record  of  this  affection. 
Described  only  in  some  ancient  works,  such  as  the 
writings  of  Pare,  it  had  been  forgotten  by  the  modems, 
when  numerous  instances  of  it  were  suddenly  m^t 
with  by  English  and  German  surgeons,  and  soon  af- 
terwards by  Desault,  who  illustrated  and  confirmed 
the  practice  of  his  predecessors  iivit,  and  even  added 
something  of  his  ovvn. 


326 

3.  All  the  joints  may  become  the  seat  of  these 
concretions;  Haller  found  many  of  them  in  that  of  the 
lower  jaw;  Bell  mentions,  as  a  very  rare  occurrence, 
their  existence  at  the  junction  of  the  foot  with  the  leg. 
Some  authors  have  met  with  them  in  the  wrist;  but 
none  are  more  common,  or  merit  more  particular  at- 
tention, than  those  that  exist  in  the  joint  of  the  knee. 
To  these  alone  shall  the  following  observations  be 
confined,  because  these  alone  have  fallen  under  the 
notice  of  Desault. 

OF   THE   VARIETIES. 

4.  Concretions  of  die  joints  do  not  always  assume 
the  same  aspect.  They  vary  greatly  as  to  number, 
size,  figure,  structure,  &:c.  In  general,  these  bodies 
exist  aingly ;  sometimes,  however,  two  of  them  are 
found  in  the  same  joint,  and  then  they  may  be  ex- 
tracted either  at  the  same  time,  or  in  succession,  as 
was  once  done  by  Desault.  Some  English  surgeons 
have  also  met  with  two  concretions,  and  Morgagni 
has  found  even  twenty-five,  in  the  S9.me  joint. 

5.  They  vaiy  also  in  size.  The  largest  ever  met 
with  by  Desault,  was  fourteen  lines  in  its  longest, 
and  ten  in  its  shortest  diameter.  Six  lines  diameter 
in  every  dii'ection,  was  the  measure  of  the  smallest 
one  that  occurred  in  his  practice. 

6.  Their  figure  is  sometimes  lenticular  and 
smooth  on  both  sides,  sometimes  unequal,  rough  in 
one  part,  even  in  another,  concave  on  one  side,  con- 
vex on  the  opposite,  sometimes  marked  around  the 


327 

circumference  and  sometimes  not  with  reddish 
points,  and  having  occasionally  a  stem  of  a  cellular 
texture  and  of  some  length,  as  may  be  seen  in  a  paper 
by  Theden.  They  usually  consist  of  a  single  mass, 
but  ai'e  in  some  cases  divided  into  several  lobules 
united  by  a  kind  of  ligaments,  as  in  the  fourth  case 
related  in  the  Journal  of  Surgery.  Though  most  fre- 
quently detached  and  floating  in  the  interior  of  the 
joint,  they  have  yet  been  found  adhering  by  means  of 
small  portions  of  cellular  substance,  loose  and  capable 
of  being  stretched,  or  tight,  hard,  and  even  of  a  liga- 
mentous nature. 

7.  If,  from  the  external  figure,  we  pass  to  the 
structure  of  these  bodies,  w^e  will  find  them  existing 
in  three  different  states.  Sometimes  purely  cartila^- 
ginous,  sometimes  completely  bony,  they  at  other 
times  partake  of  both  these  states,  in  which  case  a 
bony  nucleus  is  covered  with  a  cartilaginous  crust. 
Out  of  five  cases,  recorded  by  Desault,  three  are  of 
the  first,  and  two  of  the  third  kind.  Many  authors 
have  met  with  the  second  kind,  particulai'ly  Morgagni, 
who  has  even  found  in  the  same  joint,  some  bodies 
of  a  bony  and  others  of  a  cartilaginous  nature.  Hence 
it  appears,  that  this  variety  of  structure  is  to  be  attri- 
buted to  the  longer  or  shorter  standing  of  the  disease, 
that  every  concretion  must  pass  successively  through 
these  thi-ee  states,  and  that  there  is  a  great  analogy 
between  the  formation  of  such  bodies  and  natural 
ossification. 

8.  If  we  examine  a  body  of  the  third  kind  cut  in 
two  through  the  middle,  we  will  find  it  red  and  vas- 
cular in  the  centre,  like  an  epiph3^sis,  even  when  it  is 


328 

floating  in  the  joint  perfectly  loose  and  free  from  ad«( 
hesion. 

9.  Bell,  in  his  treatise  on  surgery,  speaks  of  a 
kind  of  tumour,  at  first  soft,  membranous,  and  adher- 
ing to  the  internal  surface  of  the  capsule,  but  which, 
according  to  him,  may  become  aftei-wards  hard  and 
solid,  and  be  detached  so  as  to  float  loose  in  the  joint. 
But  are  not  these  tumours  different  in  their  nature 
from  tliose  destined  to  be  converted  into  bone?  Do 
they,  in  fact,  ever  undergo  the  changes  mentioned  by 
Bell  ?  Desault  having  never  met  with  any  of  them, 
was  unable  to  offer  an  opinion  on  the  subject.  In  the 
mean  time,  an  observation  made  by  Monro,  may 
serve  to  throw  some  light  on  the  question :  he  once 
sa^v,  in  one  of  these  productions,  a  cellular  nucleus 
surrounded  by  a  covering  of  bone. 

10.  Though  usually  simple  and  fi-ee  from  com- 
plication, this  affection  may,  according  to  some 
authors,  give  rise  occasionally  to  a  dropsy  in  the 
joint.  Pare  is  the  first  who  has  made  mention  of  this: 
he  found  one  of  these  bodies  in  a  patient's  knee,  into 
which  he  had  made  an  incision  for  the  purpose  of 
di'awing  off"  a  collection  of  water.  Simson,  on  extract- 
ing a  similar  body,  gave  vent  to  four  ounces  of  v/ater. 
But,  as  on  the  one  hand,  a  dropsy  of  a  joint  often- 
times exists  without  these  foreign  bodies;  so,  on  the 
other,  these  bodies  are  almost  always  found  discon- 
nected from  dropsy.  Nor  is  there  any  afliinity  between 
the  acknowledged  causes  of  an  accumulation  of 
synovia,  and  the  presence  of  these  bodies ;  so  that 
when  the  tv/o  diseases  do  exist  together,  it  is  alto- 
gether probable,  that  they  are  independent  of  each 
other. 


32^ 
§IIL 

OF  THE  CAUSES. 

11.  The  formation  of  articular  concretions  suc- 
ceeds frequently  to  blows  or  falls  received  on  the 
joint,  in  which  case,  a  swelling  more  or  less  con- 
siderable in  the  surrounding  soft  parts,  showing 
itself  from  the  first,  and  remaining  for  some  time,  at 
length  allows  the  foreign  body  to  be  perceived,  and 
does  not,  in  general,  disappear  during  the  continu- 
ance of  the  body  in  the  part, 

12.  Sometimes  no  external  injury  contributes  to 
the  formation  of  the  body,  and  then,  a  spontaneous 
swelling  precedes  its  detection,  as  Desault  observed 
in  two  patients,  where  nothing  was  known  to  have 
concurred  in  the  production  of  the  disease.  Constant 
rest  increases  this  swelling,  while  exercise  and  a  tem- 
perate mode  of  life  diminish  it. 

13.  But  what  can  be  the  immediate  cause  of 
these  tumours?  Are  they,  as  some  allege,  an  aggre- 
gation or  crystallization  of  particles  of  matter  con^^ 
veyed  into  the  interior  of  the  joint  by  the  synovia,  in 
die  same  mamier  as  the  rudiments  of  a  stone  are  con^ 
veyed  into  the  bladder  by  the  urine  ?  Their  organic 
appearance  and  the  vessels  that  pervade  them,  are 
anfevourable  to  such  an  opinion.  Can  they  be,  agree- 
ably to  the  conjecture  of  Theden,  articular  ^ands 
bruised  by  means  of  strokes  or  falls?  Or  are  they, 
as  some  authors  will  have  it,  portions  of  the  car- 
tilage of  the  joint,  detached  by  the  same  causes? 
How  then  will  their  spontaneous  formation  be  ex- 
plained? 43 


S30 

But  why  trouble  ourselves  about  the  cause,  pro- 
vided we  can  remedy  the  effects?  Nature  conceals 
from  us  the  means,,  and  discloses  to  us  nothing  but 
the  results.  Theories  are  fluctuating ;  but  experience 
is  stiilthe  same:  let  us  search,  then,  by  an  attention 
to  facts,  for  that  which  we  cannot  learn  firomi.  first 
principles. 

^  IV. 

OF   tHE    SIGNS. 

14.  The  phenomena  which  announce  the  presence 
of  foreign  bodies  in  the  joint  of  the  knee,  are  some- 
times clothed  in  a  character  of  such  evidence,  that 
they  cannot  be  mistaken ;  at  other  times,  the  nar.ure 
of  the  disease  eludes  the  most  accurate  researches : 
the  cause  of  this  variety  may  be  easily  perceived. 

As  the  joint  presents  different  depressions  and 
eminences,  and  as  the  bodies,  being  usually  loose 
and  detached,  may  tmvel  thi'ough  its  whole  extent, 
they  produce  different  effects,  according  to  the  par- 
ticular situations  which  they  occupy.  If  lodged  in  a 
depression,  they  are  not  compressed,  and  cannot,  of 
course,  give  rise  to  any  troublesome  affection.  If 
they  bear  on  an  eminence,  such  as  the  condyls,  or 
the  posterior  part  of  the  rotula,  they  aie  forcibly 
compressed,  and  must  derange,  in  som.e  measure, 
the  functions  of  the  joint.  Hence  the  precise  nature 
of  the  affection  caimot  be  at  all  times  derived  from  the 
State  of  the  symptoms, 

15.  Sometimes  the  patient  can  stand  and  walk 
with  perfect  freedom  and  ease,  while,  at  other  times, 
a  sudden  pain  seizing  him,  obliges  him  to  sit  down, 


331 

or  even  causes  him  to  fall,  if  there  be  nothing  at  hand 
^o  support  him.  This  pain  subsists  for  a  longer  or 
shorter  time.  One  motion  produces  it,  and  some- 
times another,  made  in  an  opposite  direction,  removes 
it.  But  in  common  it  is  of  some  continuance,  and 
then  the  patient  k  obliged  to  keep  his  bed- 

16.  If  the  state  of  the  joint  be  examined,  it  will 
'be  found  more  or  less  swollen,  when  the  pain  is  very- 
acute.  When  the  pain  ceases,  the  swelling  in  part 
disappears.  It  is  never  sufficient  to  prevent  the  fin- 
gers, when  dra^vn  along  the  external  surface  of  the 
joint,  from  discovering  the  presence  of  the  foreign 
body,  when  it  forms  a  protuberance  under  the  inte- 
guments. It  is  then  found  sometimes  above  the 
rotula,  by  the  side  of  the  tendon  of  the  extensor 
muscles,  and  that  is  the  (place  where  it  usually  pro- 
duces least  pain;  at  other  times,  it  is  lower  down,  in 
ir-ont  of  the  condyls,  and  by  the  side  of  the  rotula. 
It  is  occasionally  found  immediately  behind  the  ten- 
don of  the  extensor  muscles ;  in  this  case  so  acute  is 
the  pain,  that  the  patient  is  generally  unable  to  stand. 
But  it  is  when  it  is  situated  behind  the  rotula,  near  to 
the  projecting  ridge  Avhich  runs  across  its  posterior 
surface,  that  it  gives  rise  to  the  most  serious  affections. 

17.  The  body  passes  from  one  place  to  another, 
on  the  least  motion,  and  sometimes,  as  Bell  observes, 
the  patient,  on  changing  his  position  during  sleep,  is 
awakened  by  severe  pain,  in  consequence  of  the  fo- 
reign body  being  moved  by  this  change.  It  happens, 
in  certain  cases,  that  it  disappears,  and  lies  concealed 
for  some  time,  in  the  back  part  of  the  joint.  During 
ihis  period  the  joint  performs  all  its  functions  with 


302 

freedom  and  ease.  Desault  made  this  remark,  in  the 
case  of  a  captain  of  dragoons,  from  whom,  for  the  first 
time  in  his  practice^  he  extracted  one  of  these  bodies, 
and  who,  for  six  months  previously,  had  been  able  to 
perform  all  the  motions  of  the  joint  freely,  without 
pain.  This  person,  experiencing  no  uneasiness,  con- 
sidered himself  perfectly  cured,  when  the  body  sud- 
denly reappeared,  in  consequence  of  a  hasty  extension 
of  the  leg. 

18.  If  the  body^,  when  projecting  under  the  inte- 
guments, be  gently  compressed,  it  yields  to  the  pres- 
sure, changes  its  situation,  and,  according  to  the  im- 
pression it  has  received,  moves  either  to  the  internal 
or  the  external  side  of  the  joint,  or  reciprocally  from 
one  side  to  the  other,  passing  also  behind  the  rotula, 
behind  the  inferior  ligament,  or  sometimes  behind  the 
tendon  of  the  extensor  muscles.  In  these  alternate 
displacements,  it  may  in  some  cases  be  turned  round, 
in  such  a  manner  that  its  anterior  surface  will  take  the 
place  of  its  posterior  one,  and  then  resume  its  primi- 
tive situation.  Desault  met  with  an  instance,  in  which 
the  patient  himself  was^  in  the  habit  of  turning  the 
body  round  in  this  mamier. 

19.  Bell,  in  conformity  to  the  distinction  of  arti- 
cular concretions  into  cellular  and  solid,  attributes  to 
each  division  its  peculiar  signs.  In  the  first  case,  the 
pains,  being  rather  obtuse  than  sharp,  are  constant; 
in  the  second,  they  are  extremely  acute,  but  disap- 
pear and  return  at  intervals.  Supposing  the  division 
to  be  a  real  one,  cases  of  the  last  description  certainly 
occur  much  more  fi*equently  than  those  of  the  first. 


333 

OF  T8E  TREAtMENt. 

20.  From  what  has  been  said  it  follows,  1st,  that 
these  cartilages  floating  through  the  joints,  do  mischief 
mechanically  (14),  by  coming  into  contact  with  the 
articular  surfaces :  2dly,  that  to  obviate  this  mischief, 
it  is  necessary  either  to  prevent  their  contact,  by  fix- 
ing the  bodies  in  a  spacious  part  of  the  joint,  and  thus 
doing  constantly  what  nature  does  on  certain  occasi- 
ons, or  to  extract  tiiem  through  an  opening  made  into 
the  articular  cavity. 

21.  Hence,  art  can  have  recourse  to  but  two  me- 
thods of  cure,  all  hope  of  discussing  these  tumours 
by  external  applications  being,  as  Bell  observes, 
entirely  extinguished. 

22.  The  first  method  was  proposed  by  Middleton 
and  Gooch,  who  having  brought  the  foreign  body 
into  a  situation  where  it  produced  no  pain,  endea- 
voured to  confine  it  there  a  length  of  time  sufficient  to 
mskc  it  form  adhesions  with  the  corresponding  part 
of  the  capsule.  As  we  are  not  informed  of  the  result 
of  the  experiments  of  these  two  physicians,  we  are 
left  to  our  own  conjectures  on  the  subject. 

23.  Are  these  foreign  bodies  capable  of  forming 
adhesions?  Supposing  they  are,  will  the  internal  sur- 
face of  the  capsule  attach  itself  to  them  at  the  pleasure 
of  the  surgeon?  Even  admitting  the  existence  of 
botla  diese  conditions,  by  what  means  can  the  bodies 
fee  kept  stationary  for  a  length  of  time  sufficient  for 
^e  formation  of  these  adhesions?  Will  they  not  be 


5U 

displaced  by  the  slightest  motion?  Besides,  experi- 
•ence  seems  to  be  unfa\^urable  to  the  expedient,  I 
have  already  said  (17)  that,  in  a  certain  case,  the 
foreign  body  disappeared  for  six  months,  remaining, 
no  doubt,  during  that  whole  time,  in  the  same  place : 
but,  if  it  could  not,  on  that  occasion,  form  adhesions, 
if  a  motion  was  sufficient  to  produce  its  reappearance, 
can  we  expect  that  art  will  be  more  fortunate  in  her 
attempts? 

24.  But,  even  admitting  that  the  foreign  body 
does  form  these  adhesions  with  the  capsule,  if  it 
should  increase  in  size  in  the  part  of  the  joint  which 
it  occupies,  becoming  in  a  short  time  disproportioned 
to  its  extent,  it  will  impede  motion  as  before,  and 
produce,  by  degrees,  nearly  the  same  affections. 

25  From  these  considerations  it  follows,  that  the 
only  expedient  which  can  promise  a  radical  cure  is, 
the  extraction  of  the  foreign  body.  In  the  perform- 
ance of  this  extraction,  an  incision  must  first  be  ma^ 
through  the  integuments  and  the  capsule, 

26.  This  operation,  simple  and  easy  in  itself,  has 
^iven  rise  to  apprehensions  as  to  its  consequences, 
which  have  long  prevented  practitioners  from  under- 
taking it. 

It  was  in  former  times  a  maxim  in  surgeiy,  that 
^vounds  of  the  joints  are,  if  not  mortal,  at  least  ex- 
tremely dangerous,  in  consequence  of  their  admit- 
ting air  into  contact  with  the  aiticulating  surfaces. 
But  observation  has  demonstrated  the  fallacy  of  this 
doctrine,  and  Desault  in  paiticuW,  has  tlirovvTi  great 
light  on  the  subject,  as  I  have  fi'equently  had  occasion 
to  mention  in  the  course  of  this  uT)rk:  so  that,  at 


3S5 

the  present  day,  it  is  clearly  ascertained,  that,  if  jadi- 
ciously  treated,  these  wounds  are  seldom  productive 
of  serious  consequences. 

27.  Hence  it  follows,  that  the  operation  we  are 
considering,  when  skilfully  performed,  never  gives, 
rise  to  any  dangerous  or  disagreeable  affections.  Ex- 
perience has  proved  the  truth  of  this  assertion  in  the 
practice  of  Theden,  Simson,  Gooch,  Broomfield,. 
Bell,  and  Desault,  the  latter  of  whom  performed  the 
operation  five  times  with  complete  success.  The 
only  case  in  which  he  was  less  fortunate,  was  that  of 
a  man,  in  whom  the  wound  of  the  integuments  closed 
up  at  first  without  any  accident,  but  which  was  suc- 
ceeded by  two  abscesses,  one  in  the  thigh,  and  the 
other  in  the  leg,  but  without  any  afiection  of  the  in- 
terior of  the  joint.  This  patient  was  subject  to  a  wan- 
dering rheumatism,  which  oftentimes  attacked  the 
lower  extremities,  and  was  perhaps  in  the  present 
case  the  chief  cause  of  the  unfavourable  occurrences. 

28.  It  is  to  the  English  that  we  are  indebted  for 
the  first  operation  performed  for  the  extraction  of 
these  bodies.  An  account  of  this  is  given  in  the 
Transactions  of  a  society  in  Edinburgh.  Since  that, 
the  operation  has  been  firequently  repeated,  and  more 
than  ten  instances  of  it  were  already  on  record,  when 
Pesault  first  performed  it  in  France.  His  method, 
somewhat  different  from  that  of  others,  was  as  fol- 
lows. 

1st,  The  patient  must  be  laid  on  a  bed,  or  seated 
on  a  high  chair.  The  first  position,  however,  is  to 
be  preferred,  because  when  it  is  adopted,  the  patient 
need  not  be  moved  after  the  operation^ 


336 

2dly,  The  leg  Is  extended  on  the  thigh,  in  Ofd<^ 
to  relax  the  anterior  part  of  the  capsule  of  the  joints 

3dly,  The  surgeon  then  searches  for  the  foreign 
body,  moves  it  to  the  internal  side  of  the  joint, 
against  the  attachment  of  the  capsule,  and  secures  it 
between  his  thumb  and  the  fore-finger  of  his  left 
hand,  while  an  assistant  draws  the  skin  over  tlie  fore 
part  of  the  rotuia. 

4thly,  Taking  then  a  common  bistoury,  he  makes, 
on  the  protuberance  formed  by  the  body,  a  longitu- 
dinal incision  of  an  extent  proportioned  to  its  size, 
through  both  the  integuments  and  the  capsule,  so  as 
to  lay  the  body  bare  at  the  first  stroke. 

Stilly,  Sometimes  the  body  escapes  immediately 
of  its  own  accord,  in  consequence  of  the  compression 
made  on  it  by  the  fingers.  If  its  passage  out  be  not 
spontaneous,  a  small  scoop  or  a  taper-pointed  spatula 
passed  under  it,  answers  the  purpose  of  extracting  it. 
But,  in  the  introduction  of  these  instruments,  it  is 
necessary  to  avoid  touching  the  articulating  surfaces 
with  their  ends,  lest,  by  being  irritated,  they  might 
swell,  and  give  rise  to  troublesome  accidents. 

6.  If  any  resistance  be  met  with,  enlarge  the  open- 
iTig  and  the  extraction  will  become  easy.  Without 
this  precaution,  the  edges  of  the  wound,  being  bruis- 
ed and  irritated  by  the  passage  of  the  body,  will  swell, 
infiame,  and  unite  again  with  diificulty. 

7.  When  the  extraction  is  finished,  the  assistant 
who  draws  the  skin  towards  the  inside  of  the  joint, 
suddenly  lets  it  go,  v.  hen  it  returns  to  its  natural  situ- 
ation. This  causes  the  two  incisions,  which  corres- 
ponded, at  the  time  of  the  operation,  to  change  their 


337 

relative  situation,  the  one  remaining  internal  and 
the  other  becoming  external. 

8.  Hence  arises  a  twofold  advantage ;  the  entrance 
of  air  into  the  interior  of  the  joint  is  prevented,  and 
the  external  and  loose  portion  of  the  capsule,  being 
draM^n  inwards  with  the  skin,  unites  with  the  condyl, 
if  it  be  not  brought  into  exact  apposition  with  the 
other  portion  of  the  capsule,  divided  near  its  attach- 
ment. 

9.  The  extraction  being  finished,  it  is  then  ne- 
cessary to  examine  carefully,  in  order  to  ascertain 
whether  or  not  the  joint  contain  any  more  of  these 
foreign  bodies.  On  -some  occasions,  when  this  is 
even  the  case,  they  cannot  at  the  time  be  discovered. 
Desault  himself  was  once  deceived  on  this  score,  in 
consequence  of  which  his  patient  was  obliged  to 
submit  to  a  second  operation. 

10.  The  incision  in  the  integuments  is  now  united 
by  means  of  adhesive  plaster.  Over  this  are  laid 
compresses  and  a  little  lint,  and  the  whole  secured 
by  a  few  turns  of  a  roller  drawn  moderately  tight. 

11.  The  leg  being  then  placed  on  a  pillow,  is  kept 
in  a  state  of  extension,  by  means  af  a  splint  applied, 
for  a  few  days,/behind  the  joint. 

29.  If  we  examine  but  for  a  moment  the  process 
in  this  operation,  we  must  perceive,  that  an  incision 
made  through  the  skin  and  capsule  at  a  single  stroke, 
is,  in  no  respect,  less  advantageous  than  one  made 
at  two  strokes,  as  recommended  by  all  practitioners., 
and  that,  it  is  in  the  following  respects  greatly  pre- 
ferable to  it:    1st,   it   shortens   the  operation   very 

considerably :  2dly,  it  diminishes  the  pain :   3dly,  it 

44 


338 

exposes  the  joint  a  much  shorter  time  to  the  contact 
of  the  air. 

30.  The  object  of  the  operator  is  better  answered 
by  drawing  the  skin  outwai'd  and  towards  the  rotula, 
than  by  either  depressing  it,  as  Broomfield  did,  or 
raising  it,  as  Bell  does.  Being  more  loose  and  more 
easily  strotched  in  this  direction,  the  opening  in  it  is 
removed  farther  from  that  in  the  capsule,  which  pre- 
vents more  certainly  the  access  of  air  to  the  joint, 
and  also  favours  the  examination  of  the  capsule. 

31.  In  the  mean  time,  the  operation  may  succeed, 
even  although  the  openings  in  the  integuments  and 
the  capsule  correspond  to  each  other.  Many  English 
and  German  practitioners,  without  previously  stretch- 
ing and  changing  the  natural  situation  of  the  skin, 
make  a  common  incision,  which  they  dress  after- 
wards like  a  simple  wound,  and  are  yet  no  less  suc- 
cessful than  others  in  the  result  of  their  operations. 
This  is  a  further  proof  of  the  fallacy  of  the  ancient 
surgical  doctrine,  respecting  the  admission  of  air  into 
tl^p  cavities  of  joints.  Perhaps  Desault  might  have 
omitted  this  precaution,  had  any  operations  of  the 
kind  occurred  in  liis  practice  during  the  last  years  of 
his  life. 

32.  The  operation  is  seldom  attended  with  much 
pain.  Only  one  patient  manifested  signs  of  this  in 
the  practice  of  Desault.  Nor  have  those  operations 
of  the  kind  performed  in  England  been  more  painful, 
so  that  it  may  be  laid  down  as  a  principle,  that  in 
most  cases  no  primitive  accident  is  to  be  dreaded. 

33.  With  regard  to  hemorrhagy,  as  there  is  no 
large  artery  near  the  place  of  the  incision^  there  is 


339 

nothing  to  be  apprehended  on  that  score.  Oftefitimes 
there  is  scarcely  any  loss  of  blood  at  all,  as  may  be 
seen  in  the  first  case  published  in  the  Journal  of  Sur- 
gery.  But,  even  admitting  that  a  small  articular 
branch  be  divided,  the  reunion  of  the  edges  of  the 
wound  will  be  sufficient  to  check  the  hemorrhagy, 
in  the  same  manner  as  in  the  operation  for  the  hare- 
lip, the  contact  of  the  divided  integuments  of  the  lip, 
puts  an  end  to  the  hemorrhagy  from  the  small  arteries 
of  the  part. 

§XIV. 

OF   THE   SUBSEQUENT   TREATMENT. 

34.  I  have  already  said  that  but  little  is  to  be  ap- 
prehended on  the  score  of  accidents  subsequent  to 
the  operation  (26).  Out  of  the  numerous  operations 
of  the  kind  performed  lately  in  Europe,  but  few  cases 
have  proved  troublesome  in  their  consequences,  and 
even  these  were  influenced  by  some  foreign  circum- 
stances. Thus,  for  example,  one  of  the  patients  of 
Simson  rode  out  on  horseback  a  few  hours  after  the 
operation,  on  a  cold  and  stormy  day,  and  thus  pro- 
duced a  troublesome  affection  of  the  part.  A  similai' 
remark  may  be  made  respecting  the  case  formerly 
mentioned  (27). 

35.  The  apparatus  or  dressing  remains  uhtauched 
for  the  two  or  three  first  days,  during  which  time  it 
is  necessary  to  wet  it  fi^equently  with  vegeto- mineral 
water.  It  is  a  certain  truth,  that  the  use  of  this  liquid 
retards  the  suppuration  of  wounds,  and  that,  when 
continued  a  due  length  of  time,  it  keeps  inflammation 
at  that  degree  most  proper  for  the  process  of  healing. 


340 

26.  On  the  removal  of  the  dressing,  the  wound  is 
sometimes  so  perfectly  healed  up,  as  not  to  exhibit 
the  least  discharge.  At  other  times  a  shght  suppura- 
tion takes  .place;  but,  at  the  end  of  a  few  days,  the 
cure  is  complete.  Under  the  care  of  Desault,  it  was 
^ways  effected  in  eight  or  ten  days. 

67.  Let  us  bring  the  doctrine  just  laid  down  to 
the  test  of  experience.  Five  cases  have  been  pub- 
lished on  this  point.  I  have  selected  two  of  them,, 
both  which  occurred  in  the  same  subject,  where  we 
find  the  same  operation  twice  performed  with  equal 
success. 

Case  I.  M.  Vielle,  aged  nineteen,  was  attacked 
about  the  beginning  of  the  year  1790,  by  a  spontane- 
ous swelling  in  the  joint  of  the  knee.  Inconsiderable 
at  first,  but  increased  afterwards  by  a  laborious  jour- 
ney, it  disappeared  at  the  end  of  two  months,  disco- 
vering to  the  touch,  near  the  internal  tdge  of  the 
rotula,  a  foreign  body,  which  was  hard  and  moveable, 
and  which  somewhat  impeded  the  motions  of  the 
joint. 

About  a  month  afterwards,  the  swelling  returned, 
and,  having  continued  for  three  months,  disappeared 
again,  when  the  body  was  found  at  the  external  side 
of  the  rotula,  increased  in  size.  Sundry  external  ap- 
plications were  tried  for  six  months  without  success.. 

Weary  of  this  unavailing  practice,  the  patient 
came,  in  March,  1791,  to  consult  Desault,  who  dis- 
covered a  cartilaginous  substance  of  a  flat  and  circular 
figure.  Its  usual  situation  v/as  at  the  external  side  of 
the  joint,  but  it  could  be  easily  moved  to  the  internal 
side,  and  could  be  turned  on  its  own  axis  within  the 


341 

joint,  nbr  did  it  occasion  any  pain,  when  suffered  to 
remain  at  rest  by  the  side  of  the  rotula.  But,  when 
it  passed  behind  the  tendon  of  the  extensor  muscles, 
the  patient  was  unable  to  stand,  and  he  experienced 
severe  pains  when  it  made  its  way  under  the  condyls 
©r  behind  the  rotula. 

The  indication  was  evident.  Before  the  operation 
Desault  prepared  the  patient  by  a  proper  regimen, 
and  then,  in  the  method  already  described  (28),  ex- 
tracted a  foreign  body,  whitish,  and  oval,  fomteen 
lines  in  length,  ten  in  breadth,  and  two  and  a  half  in 
thickness  at  its  middle.  It  consisted  of  three  pieces^ 
united  by  a  ligamentous  substance,  and  was  smooth 
on  the  side  next  the  joint,  but  rough  with  irregular 
tubercles  on  the  opposite  side,  and  on  its  circumfer- 
ence. There  was  no  loss  of  blood  during  the  opera- 
tion: the  usual  dressing  was  applied,  after  the  most 
attentive  examination,  as  to  the  existence  of  a  second 


.  Neither. pain  nor  swelling  supervened,  and  by  the 
fourth  day,  the  reunion  was  complete.  In  a  short 
time  motion  was  performed  with  as  much  ease  as 
before  the  occurrence  of  the  complaint.  In  the  mean 
while,  a  degree  of  uneasiness  remained  in  the  joint; 
but  barely  perceptible  at  first,  this  uneasiness  conti- 
nued to  increase;  in  about  four  months,  symptoms 
of  the  existence  of  another  foreign  body  made  their 
appearance. 

M.  Vieile  being  now  a  distance  from  Desault,. 
put  himself  under  the  care  of  his  brother,  who  ex- 
tracted a  second  body,  in  the  manner  already  describ- 
ed, except  that  the  iacision  was  made  at  tv/o  strokes. 


I  342 

Dressing  the  same  as  in  the  preceding  case,  with 
this  additional  precaution,  that  the  thigh  and  leg  were 
covered  by  a  roller,  for  the  purpose  of  moderating 
the  action  of  the  muscles. 

No  fever,  no  pain ;  the  reunion  completed  on  the 
eighth  day,  except  a  small  point  in  the  centre  of  the 
wound,  which  suppurated  slightly  till  the  fourteenth. 
There  was  now  neither  difficulty  in  walking,  nor  the 
least  sensation  of  pain.  Since  that  time,  M.  Vielle 
has  enjoyed  the  entire  use  of  his  limb. 

OBSERVATIONS  AND  REFLECTIONS 

ON  FORMS  OF  APPARATUS  FOR  FRACTURES  OF  THE 

LEG. 

u. 

1.  Case  I.  (Reported  by  Levacher).  Catharine 
Beiet,  aged  fifty-live,  of  a  strong  and  vigorous  con- 
stitution, fractured  her  leg  in  the  middle,  by  a  false 
step  in  alighting  from  a  carriage.  Being  carried  home, 
in  a  careless  manner,  she  was  visited  by  a  surgeon, 
who  merely  reducing  the  fracture,  but  applying  no- 
thing to  retain  the  reduction,  sent  the  patient  to  the 
Hotel-Dieu.  She  was  conveyed  on  the  same  day  to 
the  amphitheatre,  where  Desault  discovered  die  ex- 
istence of  the  affection  by  the  following  signs. 

Pain  in  the  middle  of  the  leg,  less  severe  when 
the  limb  yv?^s  at  rest,  more  so  when  it  vvas  suddenly 
moved;  the  patient  absolutely  unable  to  support  her- 
self on  it  so  as  either  to  stand  or  walk  since  the  acci- 
dent;  inequalities  sensible  to- the  touch  on  the  ante- 


343 

rior  surface  of  the  tibia;  a  shortening  or  contraction 
of  about  half  an  inch ;  a  preternatural  mobility  at  the 
place  of  the  fracture;  evident  crepitation,  produced 
by  the  rubbing  of  the  fragments  against  each  other, 
when  moved  in  contrary  directions :  a  change  in  the 
direction  of  the  lower  fragment,  which  was  bent 
somewhat  outwards.  These  signs,  added  to  the  cir- 
cumstance of  the  fall,  evidently  announced  a  simple 
fracture  of  both  bones.  The  reduction  was  effected 
in  the  following  manner. 

One  assistant  made  counter- extension  by  grasping 
the  lower  part  of  the  thigh  with  both  his  hands,  the 
fingers  being  placed  behind  it,  and  his  thumbs  cor- 
responding to  its  anterior  surface.  Another  made 
extension,  not  as  writers  recommend,  at  the  lov/er 
part  of  the  leg,  but  on  the  foot  itself,  which  was  taken 
hold  of  in  such  a  manner  that  the  fingers  met  on  its 
upper  side,  while  the  thumbs  crossed  each  other  on 
its  sole.  In  this  way  a  lever  of  the  first  kind  was 
formed,  the  resistance  to  which  was  the  fragment  to 
be  replaced,  while  its  centre  of  motion  was  in  the 
joint. 

Extension  being  directed  at  first  in  the  course  or 
line  of  the  displacement,  till  the  limb  had  attained  its 
usual  length,  was  then  directed  in  such  a  way  as 
to  restore  to  the  leg  its  natural  form.  By  this,  the 
fragments  being  brought  into  apposition,  united  ex- 
actly without  the  process  of  coaptation  being  em- 
ployed.* The  apparatus,   usually  employed  by  De- 

*  That  is,  without  any  assistance  from  the  hands  of  the 
surgeon.  Trans. 


sault  in  such  cases,  was  applied  to  maintarn  the 
reduction :  the  different  pieces  of  it  had  been  pre- 
I'iously  aiTanged  on  a  pillow  in  the  follo-wing  order: 
1st,  four  strong  pieces  of  tape  placed  at  equal  dis« 
lances  from  each  other;  2dly,  a  junk- cloth,*  long 
enough  to  reach  from  the  knee  beyond  the  sole  erf" 
the  foot;  3diy,  a  bandage  of  strips,  similar  to  that 
described  for  the  tliigh  (page  246),  arranged  in  the 
usual  mode ;  4thly,  two  long  compresses,  the  lower 
one  of  which  being  the  longest  was  turned  back  on 
the  other;  three  bolsters  had  also  been  prepared; 
these,  being  formed  of  several  pieces  of  imen  joined 
togetlier,  were  about  one  inch  and  a  half  thick :  the 
broadest  of  these  was  designed  to  be  placed  on  the 
anterior  pail  of  the  leg;  the  two  other  iatei-ai  ones, 
though  narrower,  were  a  little  longer,  in  order  that, 
by  folding  back  on  themselves,  they  might  be  ac^ 
commodated  to  the  inequalities  of  the  limb;  6thly, 
lastly,  there  were  also  prepared  two  splints,  an  inch 
broad,  thi'ee  lines  thick,  and  of  the  same  length  with 
the  junk- cloth. 

Every  thing  being  ready,  the  assistants  still  keep- 
ing up  extension  raised  the  leg  a  little,  while  a  pil- 
low was  slipped  under  it,  to  support  it  equally  and 
uniformly  throughout  its  whole  length.  The  leg  was 
placed  on  this  pillow  in  such  a  \^'ay  as  to  corp^spond 
exactly  to  the  middle  of  the  apparatus  which  was 

*  Analogous  in  its  form  and  uses  to  that  employed  in  frac- 
tures of  the  thigh.    It  may  not  be  amiss,  on  tliis  occasion  to    ^ 
mention,  that  in  the  form  of  apparatus  for  obhque  fractures  of 
the  leg,  represented  in  the  Appendix,  plate  III.  no  junk-cloth  is 
necessary.  Trans, 


345 

arranged  in  order  on  it,  and  was  previously  wet  wltK 
vegeto-mineral  water. 

On  the  anterior  part  of  the  leg  was  Aen  ^plied 
a  long  compress,  extending  irom  the  knee  to  the 
tqjper  part  of  the  foot.  Over  this  were  lapped  the 
other  two  compresses,  which  had  been  previously 
fdaced  in  order  as  part  of  the  apparatus.  These  were 
then  secured  by  the  bandage  of  strips,  the  application 
of  which  was  begun  at  the  lower  strip  next  to  the 
foot,  and  contiiiued  successively  upwards  with  the 
rest,  making  them  cross  each  other  at  the  anterior 
part  of  the  leg. 

On  the  sides  W€re  placed  the  bolsters  which 
were  doubled  at  the  tmcle  to  protect  that  part  from 
the  pressure  it  might  otherwise  sustain.  The  sphnts 
were  then  applied  along  the  external  surfaces  of  the 
bolsters,  the  edges  of  tl^  junk- cloth  having  been 
previously  folded  round  them,  in  order  to  render 
iheir  pressure  the  more  close  and  steady.  Along  the 
fore  part  of  the  leg  was  laid  the  largest  of  the  bolsters, 
and  the  whole  was  then  secured  by  the  four  pieces 
of  tape  tied  on  the  external  splint,  with  a  degree 
of  tightness  sufficient  to  keep  the  fragments  im- 
moveable. 

'  A  compress  wet  with  vegeto-minergj  water 
covered  the  foot,  and  was  secured  by  a  roller,  appli- 
ed in  such  a  manner,  that  its  two  ends,  crossing  on 
the  back  of  the  foot,  were  fastened  laterally  to  the 
two  splints. 

The  leg,  being  firmly  fixed  by  this  apparatus, 
and  gently  flexed  by  means  of  a  pillow  placed  under 

it,  was  protected  by  hoops  from  the  pressure  of  the 

45 


346 

bedcloaths.  The  fragments  being  now  in  complete 
apposition  irritated  the  parts  no  longer,  in  conse- 
quence of  which  the  pain  ceased. 

The  patient  being  properly  disposed  in  bed,  re- 
mained tranquil  and  easy  throughout  the  remainder" 
of  die  day.    Diluting  drinks  and  light  nourishment 
were  prescribed.  ; 

Next  day,  no  pain;  patient  composed;  a  slight 
swelling  on  the  back  of  the  foot ;  the  apparatus  wet 
anew  with  vegeto- mineral  water.  Fourth  day,  the 
bandages  a  little  relaxed;  the  point  of  the  foot  turned 
somewhat  outwai'ds ;  a  new  application  of  the  appa- 
ratus. Seventh  day,  bilious  symptoms  appear,  loath- 
ing of  food,  nausea,  and  bitterness  of  the  mouth. 
Eighth  day,  tongue  furred,  inclination  to  vomit ;  loss 
of  appetite ;  a  grain  of  tartar  emetic  given  in  solution ; 
copious  dejections;  evidently  better:  next  day,  ap- 
petite returned,  tongue  clean.  Tenth  day,  a  third 
application  of  the  apparatus,  which  had  become  too : 
loose.  Fifteenth  day,  fresh  bilious  symptoms;  fur-, 
ther  evacuations;  success  the  same.  Twentieth  day, 
consolidation  evidently  advancing;  no  deformity  of 
the  limb;  fourth  appplication  of  the  apparatus.  Thir- 
ty-second day,  consolidation  almost  complete ;  the 
apparatus  still  kept  on  till  the  forty-second  day,  when 
the  patient  was  discharged  perfectly  cured. 

2.  This  case,  which  is  in  no  respect  different 
from  those  that  most  frequently  occur  in  practice, 
presents  us  with  a  view  of  the  mode  of  reduction,  the 
means  of  retention,  and  the  subsequent  treatment, 
employed  by  Desault,  in  cases  of  the  kind.  The  ad- 
vantage of  the  bandage  of  strips,  which  allows  the. 
limb  to  be  uncovered  without  being  disturbed,  is 


347 

now  generally  acknowledged  in  fractures  of  the  lower 
extremities.  In  the  treatment  of  these,  practitioners 
reject  entirely,  at  present,  the  roller  bandage,  which 
was  recommended  by  Petit,  Heister,  and  all  the  au- 
thors who  preceded  them,  and  which,  by  producing 
a  new  displacement,  at  each  time  of  reapplication, 
may  entirely  prevent  the  fragments  from  uniting. 
The  bandage  of  Scultet,  brought  into  use  again  by 
Dcsault,  the  form  of  which  has  been  just  described, 
is  also  preferable  to  the  eighteen-tailed  bandage, 
which  some  practitioners  still  employ. 

3.  The  strips  which  compose  the  former  bandage, 
being  narrower  than  the  tails  of  the  latter,  can  be 
more  neatly  applied  to  the  leg,  as  they  more  readily 
mould  themselves  to  its  inequalities;  the  compres- 
sion made  by  them  is,  therefore,  more  exact,  more 
uniform,  and  consequently  less  inconvenient.  If  one 
of  the  strips  become  soiled,  it  can  be  changed  with- 
out deranging  the  bandage.  (Respecting  this  point, 
see  what  was  said  on  fractures  of  the  thigh. )  This 
bandage  being  less  bulky  than  the  eighteen-tailed 
one,  is  therefore  less  troublesome  to  the  patient. 

4.  The  broad  and  strong  splints  which  form  a  part 
of  this  apparatus,  have  the  following  advantages  over 
those  previously  used  both  by  the  ancients  and  the 
moderns;  1st,  they  come  in  contact  with  and  bear 
on  a  lai'ger  extent  of  the  surface  of  the  limb ;  2dly,- 
they  consequently  maintain  the  fragments  in  apposi- 
tion with  greater  firainess  and  effect;  3dly,  they  pre- 
vent the  rotation  of  the  foot  outwards,  an  accident 
which  very  frequently  occurs  when  the  fracture  is 
complete,  that  is,  when  both  bones  are  broken;  4thiy, 
they  remain  constantly  in  their  place,  without  slip- 


ping  either  forward  or  backward,  an  incoftvenietiofr 
necessarily  attendant  on  the  other  splints,  which, 
from  their  roundish  form,  touch  the  limb  in  only  onfe 
point  or  line,  ^ 

5.  To  sustain  th€  foot,  Petit  recommends  a  piece 
of  a  board  to  be  applied  immediately  to  its  sole,  and 
supported  by  two  bits  of  tape  fastened  to  the  splints^ 
This  practice  is  adopted  to  some  extent  even  at  pre- 
sent: but  a  simple  roller,  applied  in  the  manner  alrea« 
dy  mentioned,^  is  sufficient  for  the  purpose ;  the  ten- 
dency of  the  foot  to  turn  outwaj'ds  is  never  so  strong 
as  not  to  be  effectually  resisted  by  this  expedient: 
besides,  should  the  piece  of  board  be  placed  ever  so 
little  too  vertically^  it  retains  the  foot  in  a  state  of  in- 
convenient and  painful  flexion. 

6.  The  situation  of  the  leg,  gently  flexed  by 
means  of  a  thick  cushion  or  pillow  placed  between  it 
and  the  mattress,  is,  in  all  respects  to  be  preferred  to 
the  method  of  Pott,  wliich  is  exclusively  adopted  by 
Bell.  What,  indeed,  can  be  the  object  of  this  latter 
method?  To  relax,  say  they,  the  muscles,  that  tend 
to  make  the  lower  fragment  overlap  the  upper  one*. 
But  is  it  not  evident,  that  most  of  these  muscles,  not 
being  attached  to  the  os  femoris  at  all,  cannot  be  infiu- 
-cnced  by  this  position?  To  obtain  the  relaxation  oC 
the  posterior  muscles,  it  is  necessary  toflex  the  foot j 
but,  in  such  a  case,  the  anterior  muscles  ai*e  neces- 
sarily in  a  state  of  tension:  this  completely  counter- 
balances the  relaxation  of  the  others,  and,  therefore., 
there  is  nothing  w^iatever  gained.  It  is  certainly  muohfe 
best  to  allow  the  leg  to  be  in  a  state  of  moderate  flexi* 
on,  such  as  we  assume  when  asleep,  and  which,  ap- 
pears to  be  the  most  natui'al. 


349 

7.  The  apparatus  just  described,  produces  on  the 
fragments  a  twofold  action :  1st,  by  a  kind  of  side 
walls  formed  by  the  splints,  it  prevents  their  displace- 
ment laterally,  and  from  this  circumstance  alone,  is 
fully  sufficient  for  the  retention  of  transverse  fi'aetures : 
2dly,  the  pressure  of  the  rollers,  splints,  and  bolsters, 
if  these  be  applied  with  sufficient  tightness,  prevents 
the  lower  fragment  from  mounting  on  the  upper  one, 
and  thus  preserves  the  natural  length  of  the  limb. 
Hence  its  advantages  in  oblique  fractures;  and,  as 
the  powers  of  displacement  are  weaker  here  than  in 
the  thigh,  this  apparatus,  is  in  general,  sufficient  to 
eoimteract  them. 

8.  It  is  true  that  cases  do^  sometimes  though 
rarely  occur,  where,  in  consequence,  of  being  irritat- 
ed by  splinters,  or  the  points  of  the  fractured  bone> 
or  acted  cai  by  som«  other  causes  which  make  them 
eontract,  the  m^uscles  overcome  the  resistance  of  the 
apparatus,  and  make  the  fragments  overlap.  Under 
such  circumstances,  permanent  extension  affi:^rds  here 
the  same  advantages  as  in  fractures  of  the  thigh. 

9.  Most  authors,  to  obtain  the  desired  end  in  such 
eases,  recommend  means  calculated  to  act  on  the 
thigh.  Thus,  Manne  proposes  the  use  of  his  glaus- 
socome.  Desault,  under  such  circumstances,  effected 
his  purpose  by  the  apparatus  described  in  th6  follow- 
ing case. 

10.  Case  II.  Pierre  Bejol,  aged  thirty- sevea^  of 
a  strong  and  vigorous  constitution,  fell,  as  he  was 
carrying  a  heavy  load,  over  a  beam  which  lay  in  his 


350 

way.  His  leg  was  fi-actured  towards  its  lower  part; 
he  was  lifted  up  and  carried  home,  where  a  surgeon, 
by  making  unskilful  efforts  at  reduction,  gave  him 
extreme  pain. 

A  roller  and  a  kind  of  round  splint  applied  to  each 
side  of  the  limb,  forming  the  whole  of  the  apparatus, 
and  not  being  sufficient  to  retain  the  fragments,  soon 
alloAA'ed  them  to  overlap  each  other  nearly  two  inches. 
The  pains  continue;  a  considerable  swelling  appears 
around  the  fracture;  the  patient  is  greatly  agitated; 
he  is  brought  to  the  Hotel-Dieu,  where,  from  the 
deformity  of  the  limb,  Desault  was  satisfied,  at  first 
sight,  of  the  existence  of  a  fracture ;  on  a  more  atten- 
tive examination,  it  was  discovered  to  be  complete 
and  veiy  oblique. 

The  muscles  being  tense  and  in  a  state  of  violent 
contraction,  drew  the  inferior  fragments  very  forcibly 
upwards;  these  were  finally,  however,  by  means  of 
well  directed  efforts,  brought  into  perfect  contact, 
with  the  superior  fragments :  the  difficulty  now  lay 
in  maintaining  this  contact.  The  age  of  the  patient, 
his  strength,  and  the  almost  convulsive  state  of  the 
muscles,  gave  reason  to  apprehend  that  a  displace- 
ment was  about  to  occur.  An  attempt  was  made  to 
prevent  this  in  the  following  manner. 

The  patient  being  laid  on  a  bed  properly  pre- 
pared, 

1st,  The  foot  and  the  leg  above  the  ancle,  were 
covered  by  a  bolster  or  compress,  round  which  was 
passed  a  strong  roller  intended  for  the  pui'pose  of 
making  extension.    The  ends  of  this  roller,  being 


351 

left  free,  were  carried,  one  on  the  outside,  and  the 
other  on  the  inside  of  the  limb. 

2dly,  Below  the  tubercle  of  the  tibia  was  placed 
another  bolster,  surrounding  the  leg,  and  on  this, 
was  secured  another  roller  for  the  purpose  of  counter- 
extension.  The  ends  of  this  roller,  after  crossing 
tinder  the  knee,  were  left  hanging  loose  one  on  each 
side  of  the  limb. 

3dly,  The  two  rollers  being  thus  arranged,  while 
the  assistants,  still  continued  to  make  extension,  the 
surgeon  applied  successively,  and  in  the  order  al- 
ready mentioned,  the  compresses,  the  bandage  of 
strips,  and  the  bolsters. 

4thly,  He  then  took  two  splints  with  notches  in 
their  lower  ends,  of  the  same  breadth  with  the  splints 
already  described,  but  long  enough  to  reach,  each  of 
them,  from  four  inches  above  the  knee  to  the  distance 
of  four  inches  beyond  the  sole  of  the  foot.  One  of 
these  was  applied  on  the  outside  and  the  other  on 
the  inside  of  the  leg. 

5thly,  The  surgeon  then  taking  hold  of  the  two 
ends  of  the  upper  roller,  drew  them  over  the  upper 
ends  of  the  corresponding  splints,  while  an  assistant 
crossing  the  two  ends  of  the  lower  roller  under  the 
sole  of  the  foot,  drew  the  external  end  over  the  lower 
extremity  of  the  internal  splint,  and  the  internal  end 
over  the  lower  extremity  of  the  external  splint.  Car- 
rying them,  then,  up  along  each  side,  he  brought 
them,  at  the  middle  of  each  splint,  to  meet  the  ends 
of  the  upper  roller,  to  which  they  wTre  finiily  se- 
cured by  knots,  so  as  to  make  extension  at  the  foot, 
and  counter-extension  at  the  knee.    The  two  frag- 


a52 

ments,  being  drawn  by  this  apparatus,  the  one  down 
and  the  other  up,  could  not  again  overlap.* 

On  the  same  day  the  patient  was  bled  copiously; 
a  low  diet  was  prescribed;  some  diluting  drinks  were 
administered;  and  the  whole  apparatus  was  frequent- 
ly wet  with  vegeto- mineral  water. 

Next  day,  fever;  restlessness;  blood-letting  re-r 
peated;  the  extending  rollers,  having  become  relaxed, 
were  tightened.  Third  day,  evidently  better.  Eifth 
day,  a  new  application  of  the  apparatus ;  some  swelL 
ing  of  the  foot;  a  few  small  blisters  on  the  leg;  these 
were  opened  and  dressed  with  cerate  spread  on  linen. 
Eighth  day,  the  patient  easy  and  tranquil;  a  little 
shortening  of  the  limb;  a  third  application  of  the 
bandage.  Twelfth  day,  bilious  symptoms  appear. 
Thirteenth  day,  an  emetic  given  in  solution;  symp- 
toms decline.  Twentieth  day,  the  fractured  limb  in 
a  favourable  state;  the  roller  for  extension  laid  aside; 
that  formerly  described  employed  in  its  place.  Thir- 
tieth day,  an  appearance  of  consolidation.  Tliirty- 
fourth  day,  bilious  symptoms  recur;  further  evacua- 
tions. Forty-third  day,  consolidation  perfect;  scarcely 
a  vestige  of  the  fracture  remains.  Exercise  is  repeat- 
ed for  several  days.  Fiftieth  day  the  natural  strength 
and  motion  of  the  part  completely  restored. 

11.  The  general  eaid  to  be  answered  by  every 
bandage  intended  to  retain  a  veiy  oblique  fracture  of 
the  leg,  is  evidently,    1st,  to  hold  the  knee  up,  and 

*  For  a  view  and  description  of  an  excellent  form  of  appa- 
ratus for  oblique  f\*actures  of  the  leg,  constructed  on^  the  prin- 
ciples of  that  here  d^cribedj  see  article  III.  plate  III.  of  the 
Appendix.  Thahs. 


353 

with  it  the  superior  fragments;  2dly,  to  draw  the 
lower  fragment  down :  from  this  twofold  effect  arises 
a  twofold  resistance  diametrically  opposed  to  the 
powers  of  displacement,  which  are ;  1st,  the  slipping 
down  of  the  trunk,  which  pushes  the  thigh  before  it, 
and  with  it  the  upper  fragments  of  the  leg;  2dly,  the 
action  of  the  muscles  of  the  leg,  drawing  the  foot  up- 
wards, and  the  lower  fragment  along  with  it. 

12.  But,  if  to  these  indications  we  compare  the 
bandage  described  in  the  foregoing  case,  we  will 
perceive  that  they  are  perfectly  fulfilled  by  it.  In- 
deed the  splints  forming  a  kind  of  puUies  which 
change  the  direction  of  the  rollers,  we  must  count 
on  the  action  of  these  rollers  only  from  the  part  of 
the  limb  which  they  surround,  to  the  ends  of  the 
splints  over  which  they  are  reflected:  whence  it 
follows,  that  the  two  ends  of  the  upper  roller,  reflect- 
ed over  the  superior  extremities  of  the  splints,  can- 
not be  drawn  down  along  each  of  these  splints,  v»^ith- 
out  that  part  of  the  rollers,  which  reaches  from  the 
leg  to  these  extremities,  being  drawn  up,  and  with 
k  the  knee  and  the  upper  fragment.  In  like  manner, 
the  ends  of  the  lower  roller  cannot  be  drawn  up 
towards  the  ends  of  the  upper  one,  without  those 
portions  of  them  which  run  from  the  sole  of  the  foot, 
being  drawn  down  and  pulling  the  foot  and  the  infe- 
rior fragments  along  with  them. 

13.  Hence  it  follows,  that  by  tying  on  each  side, 
one  end  of  the  upper  roller  to  the  corresponding  end 
of  the  louver  one  with  sufficient  tightness,  the  two 
indications  above  laid  down  ( 12)  ai'e  accurately  ful- 
filled. 

46 


354 

;^  '■  14.  But,  in  general,  the  common  bandage  is  suf^ 
ficient,  as  I  have  already  mentioned,  even  in  cases  of 
oblique  fractures,  to  prevent  the  ascent  of  the  lower 
fragments  on  the  upper  ones.  Desault  never  employ  w 
ed  any  others  in  the  last  years  of  his  practice,  and  it 
was  only  in  cases  of  extraordinary  disposition  to  mus- 
cular contraction,  that  he  ever  had  recourse  to  the- 
second  kind.  By  means  of  the  common  apparatus, 
he  was  able  to  prevent  the  overlapping  of  the  frag- 
ments from  forming  any  protuberance  on  the  ante-- 
rior  and  internal  part  of  the  leg. 

15.  We  must  acknowledge,  however,  tl^t  this, 
apparatus  is  liable  to  the  same  objection  with  most 
others  intended  for  permanent  extension.  The  roller 
placed  below  the  knee,  for  the  purpose  of  counter- 
extension,  surrounds  almost  all  the  muscles,  which 
tend  to  make  the  inferior  fragments  overlap  the  supe- 
rior ones,  by  draw  ing  the  foot  upwards.  By  pressing 
on  and  irritating  these,  it  favours,  and  even  excites 
their  contractions,  and,  by  that  means,  gives  rise  to 
a  shortening  of  the  limb,  tlie  very  accident  which 
the  apparatus  is  intended  to  prevent.  This  inconve- 
nience induced  Desault,  in  a  particular  case,  to  sub- 
stitute to  the  preceding  apparatus,  that  used  for 
permanent  extension  in  fractiures  of  the  thigh. 


355^ 
MEMOIR  XV. 

ON  THE   DIVISION  OF  THE   TENDO  ACHILLIS. 

1.  It  might  be  supposed  that  a  work  on  diseases 
of  the  soft  parts,  would  be  a  more  proper  place  for 
this  article,  than  the  present  one,  where  my  express 
object  is  to  treat  of  affections  of  the  hard  parts.  What 
induces  me  to  insert  it  here  is,  the  analogy  which 
exists  between  a  division  of  the  tendo  Achillis  and  a 
fracture  of  the  os  calcis,  the  light  which  the  treatment 
of  the  one  throws  on  that  of  the  other,  and  the  exam- 
ple of  the  celebrated  Petit,  who,  in  his  work  on 
diseases  of  the  bones,  speaks  also  of  this  division. 

OF   TH<E   CAUSES  AT^D  VARIETIES. 

2.  The  division  of  the  tendo  Achillis  is  the  result, 
either,  1st,  of  the  action  of  a  cutting  instrument;  or, 
2dly,  of  muscular  action :  hence  two  very  different 
modes  of  its  production,  the  one  by  a  wound,  the 
other  by  a  rupture.  The  first  is  not  a  very  rare  acci- 
dent, because  the  projection  of  the  tendon  exposes  it 
oftentimes  to  the  stroke  of  external  bodies :  the  se- 
cond, though  but  little  noticed  by  the  ancients,  has 
been  frequently  observed  by  the  modems,  since  their 
attention  was  called  to  it  by  Petit. 

3.  The  manner  in  which  the  division  is  produced 
by  a  wound,  has  nothing  particular  in  it;  that  by  a 
rupture,  takes  place  in  the  following  manner,  A  man 


356 

leaps  over  a  ditch,  but  his  spring  or  exertion  is  too 
weak ;  he  reaches  the  opposite  bank  only  with  the 
ends  of  his  feet :  the  Hne  of  gravity  not  faUing  on  the- 
ground,  the  weight  of  the  body  throws  the  feet  into 
a  state  of  violent  flexion,  the  muscles  contract  with 
great  force,  to  prevent  a  fall  backwards,  and,  at  that 
instant,  the  tendon  is  ruptured,  in  consequence  of 
being  drawn  downwards  by  the  violent  flexion  of  the 
foot,  and  upwards  by  the  effort  of  the  muscles :  hence 
it  appears  that  Petit  was  deceived  with  regard  to  the 
mechanical  cause  of  the  rupture,  which  he  considered 
as  taking  place  at  the  moment  of  the  patient's  alight- 
ing on  his  feet,  when,  as  he  said,  the  tendons  were 
surprised,  so  to  speak,  into  a  state  of  too  great  ten- 
sion. It  is  easy  to  apply  the  principles  of  this  parti- 
cular case  to  others  that  may  happen,  and  where  the 
position  may  not  be  the  same;  such  as,  when  we 
leap  on  a  table,  &c.  Sometimes  slighter  efforts  have 
produced  the  effect;  and,  as  Louis  observes,  dancers 
have  sometimes  ruptured  the  tendo  Achillis  by  mak- 
ing a  po\\'erful  exertion  on  the  pomt  of  the  foot,  as 
well  as  by  other  motions. 

4.  Divisions  produced  in  the  first  mode,  may  be 
situated  in  any  part  of  the  tendon.  Those  produced 
in  the  second,  occur  more  particularly  about  its  mid- 
dle :  to  that  part  the  effort  or  strain  is  most  forcibly 
determined,  and  there  the  resistance  is  the  weakest. 
The  rupture  of  the  tendon  may,  according  to  Petit, 
be  either  complete  or  incomplete ;  but,  if  we  consi- 
der the  simultaneous  contraction  of  the  gasti'ocnemii 
and  soleus  muscles,  and  the  intimate  manner  in  which 
their  tvro  tendons  ai'e  united  at  a  considerable  dis- 


357 

tance  above  the  heel,  it  will  be  difficult  to  conceive 
how  these  tendons  can  be  ruptured  separately.  With 
regard  to  divisions  produced  by  cutting  instruments, 
the  case  is  different:  there,  the  weapon  may  pass 
half  way  through  the  tendon  either  from  behind  or 
laterally;  and  perhaps  divisions  of  this  kind  are 
much  more  frequently  incomplete  than  otherwise, 
in  consequence  of  the  great  resistance  of  the  tendi- 
nous fibres. 

§  II. 

or  THE   SIGNSr. 

5.  The  superficial  situation  of  the  tendo  Achiftis, 
always  renders  the  diagnosis  of  its  division  easy.  It 
can  be  rendered  difficult  only  by  the  occurrence  of 
a  considerable  s"\velling,  an  accident  that  rarely  hap- 
pens. If  there  be  an  external  wound,  the  depth  to 
which  the  instrument  has  penetrated,  and  the  possi- 
bility of  sometimes  feeling  the  ends  of  the  tendon 
between  the  edges  of  the  wound,  are  the  first  eviden- 
ces of  its  division.  If,  on  the  other  hand,  the  tendon 
be  only  ruptured,  then  at  the  moment  when  the  rup- 
ture happens,  a  report  is  heard  by  the  patient,  not 
sharp,  and  like  the  crack  of  a  whip,  as  is  said  to  take 
place  when  the  plantaris  muscle  is  ruptured,  but 
more  dull  and  flat,  according  to  the  account  given  to 
Desault  by  a  patient,  whom  he  interrogated  on  the 
subject. 

6.  In  either  case,  there  occurs  suddenly,  if  not  an 
entire  inability,  at  least,  an  extreme  difficulty  in  either 
standing  or  walking:  hence  the  patient  falls,  and  is 


$5B 

unable  to  rise  again ;  but,  in  divisions  that  are  only- 
partial  or  incomplete  (4),  this  sign  does  not  occur. 
Between  the  divided  ends  of  the  tendon  there  exists 
a  depression  sensible  to  the  touch.  This  depression 
is  increased  by  the  flexion  of  the  foot,  but  diminished 
and  even  entirely  removed  by  its  extension. 

7.  The  patient  can  spontaneously  flex  the  foot, 
none  of  the  flexor  muscles  being  affected,  and  this 
flexion  may  be  carried  even  beyond  what  is  natural, 
because  the  divided  tendon  forms  no  obstacle  to  it 
behind.  Spontaneous  extension  is  also  practicable, 
in  as  much  as  the  peroneus  longus,  tibialis  posticus, 
&c.  which  remain  uninjured,  are  capable  of  producing 
that  motion.  Some  have  alleged  that  the  calf  of  the  leg 
must  be  increased  in  size  by  the  swelling  of  the  gas- 
trocnemii  and  soleus  muscles,  in  consequence  of  their 
state  of  contraction;  but  modem  experience  has 
shown,  that  there  is  but  little  reliance  to  be  placed  on 
that  appearance. 

..OP    THE    PROGNOSIS. 

8.  Divisions  of  the  tendons  are  not  in  general  dan- 
gerous. These  organs,  being  insensible  in  their  na- 
ture, ai'e  not  painful  when  niptured,  as  is  proved  both 
by  experiments  on  living  animals,  and  by  the  obser- 
vations of  surgeons  who  have  had  such  affections 
under  their  care,  more  particularly  of  Monro,  who 
experienced  the  accident  in  his  own  person.  No 
inflammation  supervenes,  and  if  a  swelling  be  some* 
times  the  consequence,  it  is  in  general  soon  dispersed, 
leaving  behind  it  nothing  serious. 


559- 

9.  Whence  arose  then  the  exaggerated  fears  of 
the  ancients  respecting  injuries  of  this  kind?  Doubt- 
less from  an  opinion  which  was  then  entertained,  that 
tendons  and  nerves  were  of  the  same  nature.  Hence 
the  severe  pains,  the  convulsions,  and  even  death 
itself,  which,  according  to  them,  frequently  happened, 
and  was  always  to  be  apprehended,  as  the  consequence 
of  injuries  done  to  these  organs.  Lamotte,  among  the 
modems,  still  enteitained  these  prejudices,  when,  in 
S5>eaking  of  affections  of  the  tendo  Achillis,  he  said, 
'*  So  dangCTOus  are  they  in  their  consequences,  that 
they  can  seldom  be  brought  to  a  favourable  termina- 
tion." 

10.  Doubtless  the  unskilful  treatment,  employed 
by  the  ancients,  in  cases  of  this  kind,  the  use  of  the 
bloody  suture  without  proper  means  to  retain  the 
parts  in  a  suitable  situation,  the  abuse  of  irritating 
remedies  applied  externally,  the  imprudent  adminis- 
tration of  oily  substances,  and,  still  more,  the  motions 
erf  the  patient,  contributed  not  a  little  to  the  produc- 
tion of  those  accidents,  which  no  longer  occur  in  the 
practice  of  the  moderns,  since  the  nature  and  treat- 
ment of  the  disease  is  better  understood.  It  has  been 
fsroved,  by  late  observations,  that  the  division  of  the 
tendo  Achillis  is  apt  to  produce  some  diminution  in 
the  size  of  the  affected  leg.  But  this  soon  disappears,, 
i»or  does  it,  indeed,  even  occur,  if,  by  a  proper  appli- 
cation of  the  bandage  y  a  speedy  union  of  the  divided 
part  be  obtained.  The  patients  of  Desault  never  ex- 
perienced it. 


360 

OF   THE  INDICATIONS  OF   CURE. 

LI.  That  I  may  present,  in  order,  what  I  have  to 
offer  on  the  treatment  of  the  division  of  the  tendo 
AchiUis,  1st,  I  will  lay  down,  with  precision,  the  indi« 
cations  of  cure  that  arise  out  of  this  division :  2dly, 
with  these  indications  I  will  compare  the  means  used 
by  different  authors,  by  which  the  insufficiency  of 
almost  all  of  them  will  be  demonstrated:  3dly,  by 
showing  the  relation  or  correspondence  that  subsists 
between  these  indications,  and  the  apparatus  employ- 
ed by  Desault,  I  will  prove  that  it  fulfils  them  suffici- 
ently, and  is,  therefore,  to  be  preferred  to  every  other. 

12.  To  bring  the  edges  of  the  division  into  con- 
tact,  and  to  retain  them  so,  are  here,  as  in  other  simple 
wounds,  the  two  general  principles  of  treatment. 
The  first  of  the  principles  presents  an  easy  indication; 
it  is  only  to  extend  the  foot  forcibly  on  the  leg.  The- 
indications  that  arise  out  of  the  other,  are  more  diffi- 
cult to  be  fulfilled. 

13.  To  form  a  proper  idea  of  these,  let  us  call  to 
mind  what  it  is  that  prevents  the  contact  of  the  divid- 
ed ends.  As  far  as  relates  to  the  lower  end,  it  is  the 
flexion  of  the  foot  on  the  leg,  and  with  respect  to  the 
upper  one,  the  contractions  of  the  gastrocnemii  and 
soleus  muscles,  which  ai'e  not  now  opposed  by  the 
continuity  of  the  tendon.  Therefore,  1st,  to  keep 
the  foot  permanently  extended;  and  2dly,  to  oppose 
the  action  of  these  muscles,  are  the  two  general  indi- 
cations or  objects  of  every  etpparatus  destined  to 
retain  the  two  ends  of  the  tendon  iu  contact. 


S61 

■  14.  But,  the  action  of  the  muscles  may  be  op- 
posed in  different  ways ;  1st,  by  keeping  the  muscles 
themselves  in  a  state  of  relaxation.  This  relaxation 
may  be  easily  effected,  as  far  as  relates  to  the  gas- 
trocnemii,  in  consequence  of  their  insertion  into  the 
posterior  part  of  the  condyls  of  the  os  femoris :  it  is 
sufficient,  for  this  purpose,  to  keep  the  leg  half-bent 
on  the  thigh:  2dly,  by  a  judicious  and  well  directed 
compression  made  on  the  muscles.  I  say  judicious 
and  well  directed,  because  it  ought  to  bear  chiefiy  on 
the  fleshy  portion,  and  not  on  the  tendon,  otherwise 
it  will  depress  its  divided  ends,  destroy  their  contact, 
and  make  them  unite,  not  Avith  each  other,  but  v/ith 
the  adjacent  parts,  and  thus  produce  considerable 
lameness.  At  the  same  time  that  care  is  taken  not 
to  depress  the  divided  ends,  these  ends  must  not  be 
permitted  to  move  from  side  to  side,  a  kind  of  dis- 
placement which  may  readily  occur,  in  consequence 
of  the  hollow  or  depression  situated  on  each  side  of 
the  tendon.  But,  the  only  expedient  to  attain  this 
twofold  purpose,  is,  to  place  in  these  hollows,  some 
soft  substance,  lint,  for  example,  which  may  project 
sufficiently  to  protect  the  tendon  behind,  and  to  re- 
tain it  laterally. 

15.  This  compression,  that  ought  to  be  made  by 
the  bandage,  appears  to  have  escaped  all  writers,  as 
none  of  them  have  given  it  a  place  among  their  means 
of  cure.  Yet,  do  we  not  plainly  perceive,  that,  by 
confining  the  muscles,  impeding  their  contractions, 
and  reducing  their  irritability  by  its  long  continued 
use,  it  must  tend  to  prevent  the  superior  end  from 

being  drawn  upwards  and  thus  separated  from  the 

47 


362 

Hiferitjf  one  ?  Will  not  compression,  in  this  case,  he: 
similar  to  the  effect  of  the  uniting  bandage,  in  trans- 
verse \\  ounds,  where  the  great  number  of  circular 
casts  Vvhich  cover  the  limb,,  are  particularly  intended 
to  weaken  muscular  action,  analogous  to  what  takes 
place  in  hare-lip,  where  the  compresses  do  as  much 
good  by  compressing  the  muscles,  as  by  bringing 
together  the  edges  of  the  divided  lip?  But  further^- 
besides  reducing  the  fcH-ce  of  the  muscles,  does  not» 
this  compression,  serve  to  prevent  the  swelling  of  the- 
limb,  an  effect  almost  inevitably  resulting  from;  its 
state  of  rest  and  deficiency  of  action?  So  far,  then,. 
from  being,  as  Louis  says,  one  of  the  inconveniencies. 
of  the  first  bandage  of  Petit,  it  constitutes  one  of  its. 
principal  titles  to  a  preference  among  practitioners. 

16.  It  appears  from  what  has  been  just  advanced^' 
(13....  15),  that  the  following  are  the  three  ends  to- 
be  attained  by  every  bandage,  intended  to  retain  the 
divided  ends  of  the  tendo  Achillis  in  contact;  1st, 
the  immobility  of  the  foot  in  a  state  of  permanent 
extension  on  the  leg;  2dly,  the  immobility  of  the 
leg,  in  a  state  of  semiflexion,  on  the  thigh;  3dly,  a- 
judicious  and  well  directed  compression  made  on  the 
whole  leg  and  foot,  but  bearing  on  the  tendon  with 
only  sufficient  force,  to  keep  it  from  moving  back-^ 
wai'd  or  laterally.  Let  us  compai'e  the  methods  of 
authors  with  these  indications. 


§.63 

tOF  THE   DIFFERENT  METHODS  OF  CUHE. 

17.  The  treatment  recommended  by  authors 
may  be  reduced  to  three  general  methods.  The  first 
consists  in  rejecting  all  artificial  aid,  and  leaving  the 
cure  to  nature  and  the  f)osition  of  the  limb.  To  the 
second  belongs  the  use  of  sutures,  intended  to  retain 
the  edges  of  the  division  together.  The  third  in- 
cludes the  different  kinds  of  apparatus  employed  for 
the  same  purpose. 

18.  First  method.  Chronological  order  places 
this  method  after  the  others.  But  this  order  must  be 
disregarded  by  him,  whose  object  is  things  rather 
than  time.  The  history  of  the  sciences  calls  some- 
times for  the  approximation  of  distant  periods,  and, 
at  other  times,  for  the  separation  of  those  already 
approximated. 

19.  Several  practitioners,  in  France  and  England, 
have  lately  proscribed  the  use  of  all  external  means, 
Pibrac  and  Dupouy  were  of  opinion,  that  the  mere 
precaution  of  the  patient  not  to  flex  the  foot,  assisted 
by  constant  rest,  was  sufficient.  Hoin  and  Gauthier 
mention  many  cases  in  confirmation  of  this  doctrine. 
M.  J.  Rodbard,  surgeon  at  Ipswich,  having  ruptured 
his  own  tendon  about  tliree  inches  above  the  heel 
in  leaping  over  a  little  rivulet,  instead  of  confining 
himself  to  bed,  continued  in  the  exercise  of  his  pro- 
fessiom  He  walked  every  day,  without  any  other 
precaution  than  that  of  not  flexing  the  foot,  and  five 
years  afterwards,  he  was  able,  as  he  mentions,  "  to 


364 

walk,  run,  mount  or  alight  fi-om  his  horse,  without 
pain,  in  a  word,  the  affected  leg  performed  its  func- 
tions as  well  as  the  other  one."  We  have  an  account 
of  a  patient  who  was  cured  without  a  bandage  by  A. 
Petit. 

20.  Was  there  indeed  a  true  rupture  of  the  ten- 
don, in  all  these  cases,  particularly  in  those  where  the 
patients  continued  to  walk  as  before  the  accident? 
Most  of  the  cases  which  we  have  seen  prove  the  im- 
possibility of  either  standing  or  walking  (6).  But, 
admitting  that  they  were  ruptures,  are  we  authorized 
to  pursue  the  mode  of  treatment  there  adopted?  Cer- 
tainly we  are  not.  None  of  the  indications  formerly 
mentioned  (16)  is  there  fulfilled.  What  is  there, 
under  such  circumstances,  to  prevent  an  im-oluntary 
motion  from  destroying  the  contact  of  the  divided 
ends,  by  forcibly  flexing  the  foot  and  extending  the 
leg?  The  limb  is  not  subject  to  any  compression. 
Should  such  an  accident  happen,  the  cure  must  ne- 
cessarily be  tedious.  Besides,  if  the  ends  be  sepa- 
rated, a  reunion  cannot  take  place,  except  by  an  in- 
termediate substance,  which,  by  filling  up  tlie  vacant 
interval  between  them,  must  lengthen  the  tendon. 
In  consequence  of  this,  the  muscles  will  be  impeded 
in  their  contractions,  and  the  foot  in  its  motions,  as 
Desault  has  oftentimes  observed  in  animals,  which 
he  left  to  themselves,  after  having  divided  the  tendo 
Achillis.  Thus,  in  a  fracture  of  the  rotula,  the  mo- 
tion of  the  limb  is  very  much  impaired,  when  die 
ligamento-cartilaginous  substance  which  unites  th^. 
fragments  is  too  long. 


565 

21.  Hence  it  follows,  that  here,  in  like  manner  as 
in  other  ruptures  of  the  tendons,  art  must  assist  na- 
ture, because  without  the  former  the  powers  of  the 
latter  will  be  insufficient. 

22.  Second  method.  The  ancients  pursued  a 
course  not  less  uncertain,  and  much  more  dangerous. 
Sutures,  sanctioned  by  general  custom,  were  extend- 
ed to  wounds  in  the  tendons,  and  were  even  more 
especially  employed  in  such  cases,  because  the  tendi- 
nous end  being  drawn  forcibly  and  greatly  displaced 
by  the  contraction  of  the  fleshy  portion  in  which  it 
terminates,  it  was  deemed  necessary  to  oppose  to  this 
force  a  greater  resistance. 

23.  What  useful  end  was  attained  by  this  practice? 
Muscular  action  v/as  left  perfectly  free ;  and  the  only 
thing  done  was  an  attempt  made  to  resist  its  effect. 
But,  in  a  short  time  the  tendinous  ends,  in  conse- 
quence of  being  forcibly  stretched  by  the  contractions 
of  the  muscles,  either  gave  way  at  the  points  where 
the  stitches  were  introduced,  or,  in  case  they  did  not 
give  way,  became  swollen,  painful,  and  inflamed,  in 
consequence  of  the  violent  distension  which  they  suf- 
fered :  hence  the  serious  affections  produced  by  such 
treatment  (9  and  10). 

24.  The  ancients,  then,  were  mistaken,  with 
respect  to  the  indications  in  this  disease,  which  are, 
not  to  resist  muscular  contraction  left  free  and  unim- 
peded, but  to  check  and  prevent  this  contraction,  by 
the  means  formerly  pointed  out  (16).  It  is  a  princi- 
ple generally  acknowledged  at  the  present  day,  that 
sutures  ought  not  to  be  used  as  a  mean  of  approxi- 
mating divided  paits,  but  only  to  keep  the  edges  of 


S66 

parts  already  approximated  in  perfect  contact.  But, 
in  the  present  case,  the  means  of  approximation  being 
sufficient  for  the  purpose  of  exact  contact,  sutures  are 
altogether  unnecessar}\  This,  however,  does  nol: 
hold  true  in  eveiy  case,  though  certain  practitioners, 
who  have  too  generally  rejected  the  use  of  sutures,  con- 
tend that  it  does.  Finally,  however,  these  means  have 
been  excluded  from,  the  treatment  of  the  division  of 
the  tendo  Achillis,  and  the  doctrine  of  the  Academy 
of  Surgery,  though  erroneous  in  many  other  cases, 
lias  established,  v/ith  regard  to  the  present  one,  the 
irue  practice. 

25.  Third  method.  It  is  to  the  celebrated  Petit 
that  we  are  indebted  for  that  method  of  treating  the 
division  of  the  tendo  Achillis,  which  consists  merely 
in  position  maintained  hy  apparatus.  Having  ascer- 
tained that  the  extension  of  the  foot  brought  the 
fragments  into  contact,  he  conceived  the  idea  of  con- 
tinuing this  extension  throughout  the  whole  treat- 
ment, for  the  purpose  of  continuing  the  contact  also. 
This  was  a  happy  idea,  the  simplicity  of  which  recom- 
mended it  to  practitioners,  and  which,,  being  once 
discovered,  has  formed  tlie  common  basis  of  all  the 
numerous  processes  devised  since  by  different  authors. 

26.  When  we  consider  the  action  of  tliese  several 
processes,  and  compare  it  with  the  indications  for-: 
merly  laid  down  (16),  we  may  divide  the  processes 
themselves  into  three  general  classes.  Thus,  some 
of  them  fulfil  only  the  first  and  third  of  these  indica- 
tions, namely,  the  permanent  extension  of  the  foot, 
and  a  regular  compression  made  on  the  leg;  others 
fulfil  only  the  fii:st  and  second,  the  latter  of  wliich 


3^" 

cOTisists*  hi  keeping  the  leg  constantly  flexed  on  the 
thigh;  while  those  of  the  third  and  last  class,  fulfil 
the  first  indication  only.  This  manner  of  classing  the 
processes,  will  shorten  the  consideration  of  each  of- 
them  individually,  since  it  is  evident  that  each  class 
is  chargeable  with  one  general  inconvenience,  namely^ 
that  of  being  deficient  with  respect  to  one  or  two  of 
the  leading  indications.  I  shall  examine  nothings 
therefore,  but  the  disadvantages  peculiar  to  each. 

27.  To  the  first  class  belongs,  almost  exclusively^ 
the  first  bandage  invented  by  Petit.  It  is  formed  by 
a  long  compress,  placed  longitudinally  behind  the- 
leg  and  foot,  and  secured  by  a  roller  applied  regularly " 
on  these  parts.  The  two  ends  of  the  compress,  being" ' 
reflected  back,  are  then  knotted  together  behind  the- 
leg  so  as  to  extend  the  foot.  This  expedient  is  sim- 
ple and  ingenious,   and  would  be  preferable  to  all 
others,   were  it  not  that,  besides  the  charge  of  not' 
fulfilling  the  second  general  indication  (16),  it  is  fur- 
ther liable    to.  the  following  objections :     1st,  thev 
compression  which  it  makes  is  injudicious  and  ill 
directed,  because  it  bears  not  only  on  the  fleshy  por- 
tion of  the  leg,  but  ako  on  the  divided  tendon,  which 
being  more  projecting  and  therefore  more  exposed, 
has  its  two  ends  pressed  down  and  separated :  2dly, 
in  somepcases,  it  does  not  maintain  the  extension  of 
the  foot  with  sufiicient  certainty :   3dly,  it  does  not 
prevent  displacement  in  a  lateral  direction, 

28.  To  the  second  class  belong,  1st,  the  celebra- 
ted slipper  of  Petit,  substituted  by  that  author  for  his 
first  bandage ;  this  machine  was  composed  of  a  slip- 


561? 

per  fixed  to  the  foot,  of  a  knee-piece*  secured  on  the 
lower  part  of  the  thigh,  and  of  a  strap  running  from 
the  one  and  fastened  to  the  other,  to  extend  at  plea- 
sure the  foot  on  the  leg,  and  to  flex  the  leg  on  the 
thigh :  2dly,  the  bandage  of  Duchanoy,  made  in. 
imitation  of  the  preceding  apparatus,  and  consisting 
of  a  simple  sock  surmounted  by  a  roller,  which  run- 
ning along  the  back  part  of  the  leg,  was  fastened  to 
another  roller  applied  round  the  lower  part  of  the 
thigh.  Besides  the  general  objection  of  not  at  all  ful- 
filling the  third  indication  (16),  tliese  processes  are 
liable  also  to  the  following  ones ;  1st,  they  fatigue 
the  toes  by  the  constant  pressure  of  the  slipper  and 
the  sock,  as  Monro  experienced  in  his  own  person, 
to  such  an  extent  that  he  was  unable  to  support  tlieir 
use;  2dly,  the  slipper  is  quite  too  complicated,  and 
is  therefore  seldom  at  hand  when  wanted.  The  ap- 
paratus of  Duchanoy,  does  not  possess  sufficient 
solidity  and  steadiness. 

29.  In  the  third  class  are  included,  1st,  the  first 
machine  of  Monro,  formed  of  a  slipper  similar  to 
that  of  Petit,  surmounted  by  a  strap  of  leather,  which 
w^as  to  be  fastened  by  a  buckle  to  a  kind  of  guetre  or 
spatterdash,  fixed  on  the  upper  part  of  the  leg;  2dly, 
the  second  apparatus  of  the  same  author,  subject, 
like  the  other,  to  several  inconveniences;  3dly,  the 
simple  apparatus  of  Schneider,  who  rested  satisfied 
with  maintaining  the  extension  of  the  foot,  by  a  splint 

*  fGenoiiilliere.J  I  believe  this  was  a  piece  of  apparatus 
made  of  leather,  somewhat  similar  to  the  top  of  a  boot,  and 
-secured  on  the  Umb  just  above  the  knee.  Trans. 


36^ 

|)Iac€d  anteriorly.  Besides  various  other  objections 
to  them,  these  are  all  Chargeable,  alike,  with  the 
radical  fault,  of  not  fulfilling  the  second  and  third 
indications  (16). 

30i  From  this  comparison  of  the  indications  (16) 
with  the  means  destined  to  fulfil  them,  it  appears 
that  there  were  material  defects  on  the  part  of  the 
latter.  Let  us  examine  whether  or  not  that  of  De- 
sault  was  better  calculated  for  the  purpose.  It  is,  so 
to  speak,  nothing  but  a  modification  of  the  apparatus 
of  Petit  (27),  but  such  a  modification  as  amounts  to 
kti  improvement  in  principle,  and  entitles  it  to  be 
called  the  apparatus  of  Desault. 

31.  The  pieces  which  compose  it  are;  a  com- 
press two  inches  broad,  and  long  enough  to  reach 
from  the  lower  part  of  the  thigh  to  the  distance  of 
four  inches  beyond  the  foot;  a  roller  five  or  six  yards 
long  and  two  inches  wide;  a  sufficient  quantity  of 
iint;  and  two  long  graduated  compresses. 

32.  Every  thing  being  ready ; 

1st,  An  assistant  supports  the  foot  and  leg,  thd 
former  in  a  state  of  great  extension,  and  the  latter 
half-flexed:  another  assistant  supports  the  thigh, 
grasping  it  about  its  middle. 

2dly,  If  there  be  a  wound  of  the  integuments,  a 
little  lint  wet  with  vegeto- mineral  water  is  laid  direct- 
ly over  the  division  of  the  tendon;  if  it  be  a  simple 
rupture,  this  precaution  is  unnecessary.  Under  the 
foot,  up  behind  the  leg,  and  the  louver  part  of  the 
thigh,  is  then  extended  the  long  compi*ess,  which  is 
to  be  secured  in  that  situation  by  the  hands  of  the 

assistants. 

48 


370 

3dly,  The  hollows  situated  at  the  sides  of  the 
tendo  Achiliis,  are  then  filled  up  with  pledgets  of  dry 
lint,  surmounted  by  the  two  long  graduated  com- 
presses, which  retain  the  pledgets,  and  must  project 
a  little  beyond  the  tendon,  because  they  are  liable 
to  be  rendered  flat  by  pressure. 

4thly,  The  surgeon  now  taking  the  roller,  makes 
at  first  several  circular  turas  round  the  toes,  fixing 
the  long  compress  there,  the  end  of  which,  being 
reflected  over  these  first  casts,  is  secured  by  a  few 
additional  ones  which  cover  the  whole  foot,  and  are 
after\^'ards  directed  obliquely  above  and  below  the 
division,  round  which  is  formed  a  kind  of  figure  of 
8,  that  brings  the  edges  of  the  wound  into  {>erfect 
contact.  If  there  be  no  wound  of  the  integuments, 
it  is  necessary  to  take  care,  lest  the  skin  interposing 
between  the  divided  ends  of  the  tendon,  should  se- 
parate them,  and  thus  prevent  their  reunion.  Ascend- 
ing, then,  by  circular  casts,  along  the  whole  leg,  and 
even  to  the  lower  part  of  the  thigh,  the  surgeon 
there  turns  down  the  upper  end  of  the  long  compress, 
and  securing  it  by  a  few  more  circular  casts,  finishes 
the  application  of  the  roller. . 

5thly,  The  apparatus  being  thus  applied,  and  the 
extension  of  the  foot  and  the  flexion  of  the  leg  firmly 
secui'ed  by  it,  the  leg  is  then  placed  on  a  pillow  or 
bolster,  one  side  of  which  corresponding  to  the  angle 
which  the  leg  forms  with  the  thigh,  assists  in  keep- 
ing it  half- flexed. 

6thly,  Should  the  long  compress  prove  insuffi- 
cient to  keep  the  foot  extended,  or  should  it,  by  be- 
coming relaxed  too  soon,  render  frequent  reapplica- 


-371 

lions  of  the  apparatus  necessaiy,  (circumstances 
which  rarely  happen  when  the  bandage  is  well  ap- 
plied), a  splint  placed  anteriorly,  as  was  the  case  in 
Schneider's  apparatus  (29),  completely  remedies  the 
defect. 

33.   On  comparing  this  apparatus  with  the  indi- 
cations formerly   laid  down,  in  the  present  disease 
(16),  we  find  it  evidently  calculated  to  fulfil  them 
with  great  exactness.     1st,  The  extension   of  the 
foot  is  permanently  secured,  both  by  the  long  com- 
press, and  by  the  splint  when  it  is  employed :  2dly, , 
the  same  compress,  aided  by  the  bolster  or  pillow 
placed  under  the  leg,  maintains  the  flexion  of  the 
leg  on  the  thigh:   3dly,  The  muscles  are  effectually 
compressed ;  their  action  is  impeded  in  part  by  the 
compression  of  the  circular  bandage,  which  does  not 
bear  on  the  tendon,  in  consequence  of  the  bolsters 
of  lint  placed  on  each  side  of  it :  these  bolsters  pre- 
vent the  tendon  both  fi^om  moving  laterally,  and  from 
being  depressed:  hence  it  follows,  that  the  action  of 
the  circular  bandage  is  precisely  confonnable  to  the 
principles  already  established  (14  and  15);  and  that 
the  whole  of  the  apparatus,  taken  together,   fulfils 
perfectly  all  the  indications  (16);  this  is  an  advantage 
not  to  be  derived  from  any  of  the  forms  of  appai-atus 
used  by  preceding  authors. 

34.  This  apparatus  is  in  no  degree  complex  or 
troublesome.  Simple  and  easy,  it  requires  nothing 
for  its  construction  but  what  the  surgeon  can  easily 
obtain,  and  what  he  can  e\^en  himself  prepare.  There 
exists  a  great  analogy  between  it  and^the  bandages 
which  Desault  used  for  tlie  reunion  of  transverse 


372 

wounds,  aiid  for  fractures  of  the  rotula  aixj  the  olecra- 
non. A  truly  great  man  does  not  estimate  his  merit, 
t)y  the  number  of  processes  which  he  invents ;  he  well 
knows  that  the  perfection  of  art  consists  in  producing 
numerous  effects  by  few  and  simple  means. 

35.  We  will  confirm,  by  two  cases,  the  principles 
laid  down  in  this  memoir.  One  of  thes^  relates  to  £^ 
division  of  the  tendon,  connected  with  a  wound,  and 
was  reported  by  Bezard;  the  other  by  Maiiouri,  an<J 
relates  to  a  simple  rupture  of  the  tendon. 

Case  I.  J.  3«  Lavigne,  aged  thirty,  as  he  was 
going  down  into  a  cellar  without  light,  struck  his  leg 
against  the  edge  of  a  sharp  saw,  which  completely 
divided  the  tendo  Achillis.  The  patient  was  immedi- 
ately carried  to  the  Hotel-Dieu.  The  wound  of  the 
integuments  was  transverse,  two  inches  long,  and 
had  its  edges  but  slightly  separated  from  each  other. 
The  ends  of  the  tendon,  in  contact  during  the  exten^ 
sion  of  the  foot,  were  separated  two  inches  \vhen  it 
was  flexed. 

The  usual  apparatus  was  applied  (32),  and  the 
limb  placed  on  a  bolster,  in  a  position  favourable  for 
the  relaxtition  of  the  posterior  muscles. 

In  the  evening,  wound  painful;  pulse  raised;  a 
copious  blood-letting;  low  diet.  Next  day,  mca?e 
blood  taken  away ;  antiphlogistic  regimes,  which 
was  continued  for  several  days,  till  the  symptoms 
were  gone :  no  troublesome  accident  occurred.  Tenth 
day,  the  apparatus  taken  off;  the  wound  partly  healed; 
the  apparatus  reapplied,  and  continued  till  the  twen- 
tieth day,  when  the  perfect  reunion  of  the  parts  ren- 
dered its  further  use  unnecessary,  jfron)  ^i^  tijm 


373 

the  patient  began  to  walk  on  crutches.  Thirty-sixth 
day,  could  walk  well  without  his  crutches.  At  this 
period,  a  small  abscess  occumng  in  his  heel,  induced 
him  to  remain  in  the  Hotel-Dieu  two  weeks  longer, 
when  he  was  discharged  perfectly  cured. 

Case  II.  M.  Delp,  leaping  with  some  of  his 
young  companions,  ruptured  the  tendo  Achillis, 
about  two  inches  above  the  os  calcis.  Both  standing 
and  walking  became  instantly  impracticable :  tlie  pa- 
tient falling  down,  was  taken  up,  carried  home,  and 
j&om  thence  to  Paris,  where  he  aiTived  in  the  even- 
ing. Desault  being  immediately  called  to  him,  found 
him  affected  with  all  the  signs  of  a  division  of  the 
tendon;  such  as,  a  hollow  between  its  divided  ends, 
which  was  increased  by  the  flexion  of  the  foot,  dimi- 
nished by  its  extension,  he.  The  usual  apparatus 
was  immediately  applied,  and  as  the  patient  felt  but 
little  pain,  only  a  moderate  blood-letting  was  pre- 
scribed. Next  day,  no  alteration  in  the  treatment; 
antiphlogistic  regimen ;  low  diet  continued  few  some 
days,  when  the  patient  was  permitted  to  return  to  his 
ijsual  mode  of  living.  Ninth  day,  apparatus  removed 
for  the  first  time :  a  slight  separation  of  the  ends  of 
the  tendon;  and  a  wrinkle  in  the  skin  interposed  be- 
tween them:  a  new  application  of  the  bandage, 
taking  care  to  free  the  integuments  from  wrinkles. 
Twelfth  day,  a  relaxation  of  the  rollers;  a  third  ap- 
plication of  the  bandage  :  every  thing  found  in  a  good 
^tate ;  but,  the  patient  being,  from  sprightliness,  too 
much  inclined  to  exert  himself,  a  splint  was  applied 
anteriorly  to  prevent  the  extension  of  the  foot.  Seven- 
teenth day,   a  fourth  application  of  the  apparatus. 


374 

which  was  not  moved  again  till  the  thirtieth.  At  this 
period,  the  reunion  was  somewhat  advanced :  fortieth 
day,  almost  complete.  Fiftieth  day,  the  patient  was 
permitted  to  leave  his  bed,  and  take  very  gentle  ex- 
ercise, which  he  continued  to  increase  gradually,  till 
the  sixtieth  day,  when  he  was  discharged  cured. 
Doubtless  the  tediousness  of  this  case  was  owing  to 
the  slight  separation  which  existed  fQr  some  time 
between  the  fragments. 


MEMOIR  XVI. 

ON  THE  FRACTURE  OF  THE  OS  CALCIS. 
§1. 

1.  The  OS  calcis,  being  a  short  and  thick  bone, 
has  such  a  power  of  resistance,  that  it  is  but  seldom 
fractured.  Such  an  accident  does,  however,  some- 
times occur,  and  may  arise  from  two  causes,  1st,  the 
action  of  external  bodies,  which  is  rare :  2dly,  the 
contraction  of  the  gastrocnemii  and  soleus  muscles, 
from  which  it  almost  always  proceeds.  Thus,  the 
rotula  is  more  frequently  broken  by  the  action  of  the 
extensor  muscles,  than  by  blows  received  on  the  bone 
from  without:  there  is,  hovv-ever,  tliis  difference  be- 
tween the  effects  of  muscular  contraction  in  these  two 
cases,  namely,  that  in  the  former,  the  rupture  of  the 
tendo  Achillis  is  common,  and  the  fracture  of  the  os 
calcis  very  rai'e ;  wliereas  in  the  latter,  on  the  contrary, 


375 

the  rotula  is  oftentimes  broken,  while  the  tendon  of 
the  extensors  remains  almost  always  sound.  This  phe- 
nomenon is  explained  by  the  difference  between  the 
thickness  of  the  two  bones,  between  the  length  of  the 
two  tendons,  and  between  the  power  of  the  causes. 

2.  Be  the  cause  of  the  fracture  what  it  may,  it 
generally  occurs  in  that  portion  of  the  os  calcis,  called 
its  great  tuberosity,  which  projects  behind  the  astra- 
gulus,  which  corresponds  above  and  below  to  a  large 
quantity  of  cellular  membrane,  inwardly  to  the  great 
groove  of  the  bone,  externally  to  some  ligamentous 
attachments,  and  behind  to  the  insertion  of  the  tendo 
Achillis. 

3.  It  is  known,  1st,  by  an  evident  inequality  un- 
der the  heel :  2dly,  by  an  elevation,  sensible  to  the 
touch,  of  the  posterior  fragment  above  its  usual  level : 
3dly,  by  an  almost  entire  inability  either  to  stand  or 
walk :  4thly,  by  severe  pain  being  the  inevitable 
consequence  of  moving  the  foot:  5thly,  by  its  being 
practicable  to  increase  the  displacement  by  flexing, 
and  to  diminish  it  by  extending  the  foot:  6thly,  by 
the  facUity  with  which  the  posterior  fragment  may  be 
moved  in  every  direction  by  taking  hold  of  it  with 
one  hand,  and  steadying  the  foot  with  the  other: 
7thly,  by  a  swelling  more  or  less  considerable,  which 
frequently  appears  around  the  divided  surfaces. 

4.  The  ancients  gave  in  general  an  mifavourable 
prognosis  respecting  this  kind  of  fracture.  Hippo- 
crates was  apprehensive  of  some  injury  being  done 
to  the  surrounding  paits.  Pare  considered  the  case 
mortal,  on  account  of  the  laceration  of  numerous 
vessels  which  are  connected  with  the  bone.    Most  of 


3?6 

the  moderns  adopt  these  principles,  not  for  th6  fore- 
going reasons,  but  on  account  of  the  vicinity  of  the 
accident  to  the  joint  of  the  foot.  The  practice  Of 
Desault  cannot  throw  much  light  on  this  subject,  as 
he  never  had  more  than  one  or  two  such  cases  of  frac-* 
ture  under  his  care ;  but  the  analogy  of  other  frac- 
tures, situated  in  the  neighbourhood  of  joints  and 
even  extending  into  them,  induces  us  to  believe,  that^ 
if  properly  treated,  fractures  of  the  os  calcis  will  ter- 
minate as  favourably  as  those  of  other  bones. 

5.  If  we  attend  to  the  signs  just  mentioned  (3)y 
we  will  perceive  that  they  almost  all  result  from  the 
displacement  of  the  fragments.  But,  whence  arises 
this  displacement?  As  far  as  the  anterior  fragment  is 
concerned  in  it,  it  arises  from,  and  is  increased  by, 
the  flexion  of  the  foot;  and,  as  far  as  relates  to  the 
posterior  one,  it  is  to  be  attributed  to  the  contraction 
of  the  muscles  attached  to  the  tendo  Achillis,  which 
is  itself  inserted  in  that  fragment.  Hence  it  follows, 
that  the  apparatus  intended  to  prevent  this  displace- 
ment, ought,  1st,  to  keep  the  foot  permanently  ex:- 
tended  on  the  leg :  2dly,  to  prevent  the  action  of  the 
m^uscles,  by  keeping  them  in  a  state  of  habitual  re- 
laxation by  means  of  the  constant  flexion  of  the  leg 
on  the  thigh,  by  making  on  those  whose  contractions 
are  dreaded,  such  a  regular  and  well  directed  com- 
pression as  may  disqualify  them  for  contracting;  and, 
lastly,  by  placing  behind  the  posterior  fragment  some 
resisting  substance,  to  prevent  it  from  rising  up- 
wards. 


377 

6.  If  to  these  indications  we  compare  Desault's 
apparatus  for  a  rupture  of  the  tendo  Achillis,  as  de- 
scribed in  the  preceding  memoir,  we  will  readily 
perceive  Ist,  that  it  perfectly  fulfils  that  indication 
which  relates  to  the  anterior  fragment;  2dly,  that 
that  one  wliich  relates  to  the  posterior  fragment  will 
be  equally  well  fulfilled  by  the  half  flexed  state  of  the 
leg,  by  the  compression  made  on  the  muscles,  and 
by  a  thick  compress,  not  very  broad,  laid  transversely 
above  the  fragment,  secured  by  the  long  roller,  and 
afterwards  by  a  circular  bandage,  which  must  form 
here,  as  in  the  case  of  a  fractured  rotula,  a  kind  of 
figure  of  8  around  the  fracture.  This  compress  is  the 
only  modification  of  the  apparatus  requisite  to  ac- 
commodate it  to  the  particular  case  now  under 
consideration. 

7.  In  applying  the  figure  of  8  bandage  here,  as 
well  as  in  the  case  of  a  fractured  rotula,  to  prevent 
the  ascent  of  the  fragment,  it  is  necessary  to  use  the 
utmost  care  to  free  the  integuments  from  wrinkles 
both  above  and  below  the  fracture,  lest  by  getting 
between  the  fragments,  they  might  keep  them  asun- 
der, and  thus  impede  their  reunion. 

8.  Desault  used  to  relate  in  his  lectures,  the  case 

of  a  woman  whom  he  had  formerly  seen  receiving 

a  fracture  of  the  os  calcis,  by  falling  from  a  great 

height.   I  cannot  state  the  case  fully,  because  I  am 

not  in  possession  of  all  the  facts.    The  following  one 

however  drawn  up  during  the  first  years  of  Desault's 

practice  in  the  Hotel-Dieu,  will  furnish  an  example 

of  his  mode  of  treatment. 

49 


378 

Case.  A  man,  likely  to  be  arrested  by  some 
one  who  pursued  him,  leapt  frbm  a  window  nearly 
twelve  feet  high.  In  lighting,  his  feet  struck  on  a 
beam  v/hich  lay  in  his  way,  in  such  a  manner,  that 
the  fore  part  of  them  only  was  supported.  He  made 
an  effort  to  recover  his  equilibrium,  but  as  the  line 
of  gravity  of  his  body  had  nothing  to  rest  on,  he  fell 
backwards,  rose  in  order  to  make  his  escape,  but  felt 
a  second  time  unable  to  rise  again. 

When  assistance  came  to  him,  he  complained  of 
a  severe  pain  in  his  heel,  eaid  said,  that  on  falling,  he 
had  heard  a  considerable  report.  He  was  taken  up^ 
and  assisted  in  walking  to  the  Hotel-Dieu,  where  he 
did  not  arrive  without  pain,  being  able  to  bear  only 
on  the  point  of  the  diseased  foot,  and  suffering  greatr. 
ly  if  he  attempted  to  put  his  heel  to  the  ground. 

From  the  signs  mentioned  (3),  Desault  perceiv- 
ing that  there  existed  a  fracture  of  the  os  calcis,  made 
arrangements  for  reducing  it.  This  he  did  by  ex- 
tending the  foot  on  the  leg,  and  drawing  down  the 
exterior  fragment  from  the  elevation  to  which  mus- 
cular contraction  had  raised  it,  so  as  to  bring  it  into 
perfect  contact  with  the  body  of  the  bone.  He  then 
applied  the  common  apparatus  for  a  rupture  of  the 
tendo  Achillis,  with  the  modification  already  pointed 
out  (6). 

In  the  evening  venesection  was  prescribed :  tlie 
patient  experienced  sharp  pains  at  the  place  of  the 
fracture;  a  sliglit  swelling  occurred  at  the  ends  of 
the  toes;  an  anodyne  was  prescribed.  Next  day, 
evidently  better:  venesection  again.  Fourth  day,  the 
patient  is  allowed  to  return  to  his  usual  regimen. 


379 

Eighth  day,  apparatus  removed  for  the  first  time; 
fragments  in  contact.  Fifteenth  day,  a  second  appU- 
cation  of  the  bandage.  Nineteenth  day,  biUoiis  symp- 
toms. Twenty-first,  an  emetic  given  in  solution. 
Tliirty- second  day,  further  evacuations:  apparatus 
renewed.  Forty-seventh  day,  consolidation  complete. 
A  stiffness  remained  in  the  part  for  some  time,  but 
this  was  gradually  removed  by  exercise. 


MEMOIR  XVII. 

ON  COMPLICATED  LUXATIONS  OF   THE  FOOT^ 

u. 

1. Complicated  luxations  of  the  foot,  like  com^ 
plicated  fractures,  show  themselves  under  such  a  va- 
riety of  forms,  are  accompanied  by  so  many  peculiar 
affections,  and  so  many  different  circumstances  are 
connected  with  them,  that  it  would  be  difficult  to  lay 
down  rules  applicable  to  their  treatment  in  all  cases* 
On  this  subject,  indeed,  art  is  in  possession  of  certain 
general  principles,  liable  however  to  numerous  ex- 
ceptions and  modifications.  In  the  treatment  of  such 
cases,  who  can  fix  the  limits  betw^een  reduction,  and 
amputation  or  extirpation?  Who  can  point  out,  with 
precision,  where  the  one  ceases  to  be  useful  and  be- 
comes hazardous;  while  the  others  constitute  the 
only  resources  of  ait?    Experience  and  talents  alone 


380 

are  capable  of  deciding  on  these  points,  and  that  only 
in  the  chambers  of  the  sick.  It  is,  therefore,  less  by- 
precept  than  example  that  practitioners  ought  to  be 
instiTiCted  here.       \^ 

2.  To  furnish  suitable  examples  on  this  head  con- 
stitutes my  only  object  in  the  present  memoir,  which 
will  consist  of  the  histories  of  a  few  cases,  with  such 
inferences  and  remarks  as  the  occasion  may  seem  most 
naturally  to  suggest.  Here  the  practice  of  a  great 
master,  varying  his  means  with  the  varying  forms  of 
disease,  will  serve  as  models  to  those  who  may  meet 
with  similar  cases*  Our  experience  is  composed  of 
the  facts  which  we  receive  from  reading,  as  well  as  of 
those  derived  from  observation.  Who  would  have  a 
right  to  call  himself  a  surgeon,  if  he  had  no  other  title 
to  that  name,  but  such  as  resulted  exclusively  from 
his  own  personal  observation? 

3.  However  difficult  it  may  be,  as  already  observ- 
ed, to  speak  in  general  terms,  on  the  present  subject, 
we  may  yet  assert  with  safety,  that  authors  have  great- 
ly exaggerated  the  danger  of  complicated  luxations 
of  the  foot.  Terrified  at  the  extent  and  unpromising 
appearance  of  the  accidents,  these  writers  have  lost 
that  confidence  in  the  powers  of  nature  which  we 
never  ought  to  abandon.  They  have  taken  up  an 
opinion,  that  luxations  of  the  foot,  differing  in  their 
symptoms  from  otlier  luxations,  require  also  a  differ- 
ent mode  of  treatment;  that  reduction,  by  perpetuat- 
ing the  accidents  of  the  case,  must  prove  fatal,  and 
that  amputation  ought  to  be  adopted  as  the  only  re- 
source. Cases  do  certainly  at  times  occur,  where  a 
doctrine  different  from  this  would  be  fatal  in  its  effects: 


381 

such  are  those  terrible  lacerations,  where  the  foot  is 
entirely  separated  from  the  leg,  except  some  shreds 
of  flesh  with  a  few  tendons  among  them  that  still 
retain  it. 

4.  But,  provided  the  blood-vessels  have  escaped, 
and  any  hope  of  circulation  and  life  in  the  part  still 
remain,  the  success  of  reduction  should  always  be 
first  tried;  and  the  following  examples  will  show, 
what  ought  to  be  expected  from  this  practice,  when, 
accompanied  by  skilful  treatment. 

MI. 

LUXATION  OF  THE  FOOT,  COMPLICATED  BY  A 
FRACTURE  OF  THE  FIBULA,  TIBIA,  &C. 

Case  I.  (The  following  case  was  collected  by 
Leveille.)  Abraham  Genty,  aged  forty-three,  a  dealer 
in  wine,  as  he  was  running  along  the  street,  slipped, 
and  made  a  false  step  on  his  left  foot,  which  turned 
with  its  external  edge  under  him,  and  its  internal 
edge  upwards.  He  fell,  luxated  his  foot,  and  frac- 
tured the  fibula. 

The  patient  was  carried  home,  where  a  surgeon 
who  was  ignorant  of  his  profession  being  called,  did 
nothing  but  apply  a  cataplasm  to  the  foot.  In  the 
evening  the  parts  began  to  swell,  and  were  extremely 
painful;  fever  supervened,  accompanied  with  great 
restlessness.  Third  day,  to  a  rapid  increase  of  all  the 
symptoms  was  added  a  delirium ;  blood-letting  from 
the  jugular  vein  was  prescribed  to  no  purpose;  tilings 
continued  to  grow  worse  till  the  sixth  day,  when  the 
patient  was  brought  to  the  Hotel-Dieu,  in  extreme 
danger. 


'SB2 

The  following  was  then  tlie  state  of  the  parts.  A 
considerable  swelling  around  the  joint;  a  projection 
of  the  malleolus  internus,  with  a  depression  under- 
neath it;  a  preternatural  direction  of  the  tibia  before, 
and  of  the  os  calcis,  beliind ;  a  depression  near  the 
lower  end  of  the  fibula;  a  crepitation  readily  per- 
ceived, on  moving  the  fragments ;  a  large  tumour 
on  the  outside  of  the  foot :  with  a  depression  and 
mobility  of  the  malleolus  externus. 

The  luxation  was  immediately  reduced.  Exten- 
sion made  on  the  foot  and  leg  brought  the  parts 
into  their  proper  situations,  where  they  were  retained 
by  means  of  the  bandage  for  fractures  of  the  leg,  and 
four  compresses  well  secured  by  the  bandage.  One 
of  these  compresses,  being  placed  on  the  malleolus 
internus,  another  on  the  outside  of  the  foot,  a  third 
on  the  anterior  and  lower  pait  of  the  tibia,  and  the 
fourth  under  the  os  calcis,  prevented  these  different 
parts  from  being  again  displaced. 

As  soon  as  the  apparatus  was  applied,  the  pupils 
remarked  with  astonishment,  that  the  restlessness  of 
the  patient  ceased,  that  his  pains  were  relieved,  and 
his  delirium  disappeared;  he  expressed  his  surprise 
at  the  state  from  which  he  had  just  recovered,  and 
^vas  now  able  to  give  an  accurate  account  of  his  fall. 
He  was  scarcely  put  to  bed,  when  he  fell  into  a  tran- 
quil sleep,  which  lasted  three  hours.  For  six  days 
previously  he  had  not  slept  a  moment. 

In  the  evening,  the  patient  was  free  from  pain, 
and  perfectly  tranquil.  Diluting  drinks  were  prescri- 
bed, with  twenty-five  drops  of  Hoffman's  anodyne 
liquor:  the  apparatus  was  wet  firom  time  to  time 


CtHo 


with  vegeto-mineral  water:    the  patient  slept  well 
thi'oughout  the  night. 

Next  day,  the  apparatus  renewed:  the  parts  per- 
fectly in  place:  swelling  diminished;  same  means 
continued.  Sixth  day,  the  anodjTie  discontinued. 
Tenth  day,  swelling  still  less;  echymosis  gone;  a 
yeUow  colour  in  the  skin,  an  evidence  that  resolution 
is  going  forward.  Twentieth  day,  swelling  gone. 

Thirtieth  day,  tlie  fracture  of  the  fibula  healed; 
tliat  bone  slightly  separated  from  the  tibia :  the  circu- 
lar roller  drawn  tighter ;  and  a  thick  compress  placed 
on  the  external  malleolus,  to  bring  it  to  its  proper 
place.  Forty-fifth  day,  the  apparatus  for  a  fi:-actured 
leg  removed,  and  a  simple  roller  substituted  in  its 
place :  the  motions  of  the  foot  painful  and  contracted; 
a  small  gangrenous  spot  appeared  on  the  heel.  Fifty- 
fiMi  day,  the  ulcer  which  proceeded  from  this  spot 
healed :  motions  of  the  part  more  free  and  extensive. 
Sixty-first  day,  die  patient  able  to  walk  without 
assistance,  though  not  without  pain. 

5.  It  is  difficult  to  find  an  instance  where  the 
advantages  of  reduction  have  been  more  remarkable 
than  in  the  preceding  one.  The  patient  had  passed 
six  days  in  pain,  extreme  agitation,  and  uninterrupt- 
ed delirium :  the  foot  was  reduced,  and  these  unfa- 
vourable appearances  instantly  vanished,  and  were, 
succeeded  by  a  state  of  tranquillity.  Alarmed  by 
such  a  state  of  things,  the  ancients  would  doubtless 
have  proceeded  to  amputation.  Let  us  examine  into 
the  motives  which  led  Desault  to  an  opposite  line  of 
practice,  and  then  inquire  into  the  cause  of  the  suc- 
cess with  which  that  practice  was  crowned. 


384 

6.  Had  amputation  been  performed  here,  it  must 
have  been  for  one  of  the  two  following  reasons;  1st,  for 
fear  of  gangrene ;  or  2diy,  to  remove  the  unfavoura- 
ble symptoms  that  existed.  The  first  apprehension 
would  have  been  quite  visionary,  in  as  much  as  all 
the  blood-vessels  were  sound.  Would  the  second 
consideration  have  been  any  better  founded?  It  was 
perfectly  obvious,  that  the  unfavourable  symptoms 
which  existed  arose  from  the  tension  and  overstretch- 
ing of  the  parts,  in  consequence  of  the  preternatural 
position  of  the  bones  of  the  foot.  The  indication  was 
evident.  Replace  these  bones  in  their  natural  situa- 
tions, the  strained  parts  will  then  necessarily  become 
relaxed,  and  all  the  troublesome  and  alarming  symp- 
toms cease  with  the  cause  that  produced  them. 
Experience  confirmed  the  justness  of  this  reasoning. 

7.  But  the  mere  replacement  of  the  parts  would 
be  of  very  little  avail,  if  it  were  not  permanently 
maintained,  and  followed  up  by  a  judicious  mode  of 
treatment.  Without  such  treatment  there  would 
doubtless  be  reason  to  apprehend  all  that  train  of 
troublesome  consequences,  of  which  authors  speak 
in  such  frightful  terms,  and  which  arise,  not  from  the 
nature  of  the  luxation,  but  from  the  manner  in  which 
the  patient  is  treated.  A  loose  apparatus,  incapable 
of  preventing  displacement,  would  allow  the  bones 
to  be  deranged  anew,  and  to  produce  again  an  over- 
straining of  the  parts,  accompanied  with  pain,  swell- 
ing, &c.  Irritating  local  applications,  such  as  cam- 
phorated spirits  of  wine,  &,c.  would  increase  these 
pains ;  emollients  which  are  employed  in  other  cases 
would  keep  up  the  swelling. 


385. 

8.  It  follows  from  what  has  just  been  said^  that  an 
opposite  mode  of  treatment  ought  to  succeed  the  re- 
ductipn?  and  this  we  see  was  the  case  in  the  preceding 
insta??ce.  X^^^?i^:'  when  the  bones  were  once  reduced^ 
all  new  displjjcernent  was  prevented,  because  the  ap- 
paratus was  so  constructed,  as  to  counteract  the 
tendency  of  the  bones  t,o  ^9  displaced.  The  external 
edge  of  the  foot,  which  had  been  turned  outwardS;, 
■V^as  now  pusl>ed  inwards  by  a  thick  compress ;  the 
same  means  served  to  push  outwards  the  internal 
X39,alleolus,  which  |iad  received  by  the  accident  an 
in9ljiiia,tion  inwards,  and  to  push  the  anterior  part  of 
tlf^9  tibia  backward,  and  the  os  ca,lcis  forward,  both 
9f  which  were  displaced,  as  has  been  remarked,  iri 
contrary  directions.  Two  strong  splints  fixed  the 
lateral  copapresses,  while  the  anterior  and  posterior 
9nes  were  firmly  secured  by  rpljers.  In  the  midst  of 
all  these  resistances^  the  foot  being  necessarily  inx- 
ijpoyeable,  no  new  displacement  could  occur. 

9.  A  suitable  and  judicious  position,  ^n  which 
th?  foot,  raised  a  little  higliier  than  the  leg,  was  placed 
on  a  pillow  forming  an  inclined  plain,  prevented! 
^welling,  while  gentle  compression,  made  by  a  ban- 
dage, contributed  to  the  same  end.  T^is  end  was 
also  further  attained  by  the  external  topical  applica- 
tions. To  relieve  p^in  and  remove  congestion,  \yere 
here,  as  in  sprains,  the  two  indications  to  be  fulfiUedl 
To  these  indications  the  spirituous  and  the  relaxing 
applications  formerly  in  use,  ai^e  alike  opposed.  Ve- 
geto- mineral  water,  on  the  contrary,  fulfils  then; 
extremely  well.  Hence  the  necessity  of  keeping  th?» 
apparatus  constantly  wet  with  that  liquid. 

50 


386 

10.  Regimen  influences  not  a  little  the  success  of 
the  treatment.  A  strict  diet  is  necessary  during  the 
time  of  the  inflammatory  and  unfavourable  symptoms. 
Any  excess  might  then  prove  fatal.  Desault  gave,  in 
his  lectures,  an  account  of  a  woman,  who  had  her 
foot  luxated  outward,  and  the  astragulus  forward. 
Her  fever  was  considerable,  her  pains  excruciating, 
and  the  swelling  wore  an  alarming  aspect.  The  lux- 
ations were  reduced :  all  the  threatening  appearances 
vanished,  and  every  thing  seemed  to  promise  a  fa- 
vourable termination  of  the  disease.  But,  on  the 
fiftieth  day,  the  patient,  having  procured  strong  food, 
ate  largely  of  it :  in  the  evening  all  the  unfavourable 
symptoms  returned ;  the  swelling  became  great,  and 
a  £&w^  days  afterwards  she  died. 

But  if  strong  food  be  prejudicial  during  the  time 
in  which  bad  symptoms  are  to  be  dreaded,  a  diet  too 
strict  would  be  equally  injurious  when  that  time  is 
passed.  The  weakened  powers  of  the  system  would 
not  be  adequate  to  the  purposes  of  a  cure,  particularly 
to  the  consolidation  of  the  bone,  should  the  case  be 
a  fracture.  Desault,  therefore,  permitted  the  patient 
to  increase  his  diet  by  degrees,  and  at  length  to  return 
to  his  usual  regimen. 

11.  The  following  case,  reported  by  Giraud, 
proves  still  further  the  advantages  of  this  simple 
mode  of  treatment,  which,  should  it  even  fail,  always 
allows  the  surgeon  to  avail  himself  of  amputation, 
which  is  indeed  the  last  resource  of  art,  and  should 
never  be  employed  till  rendered  indispensable  by  the 
failure  of  all  other  means. 

Case  II.    Maria  Constant,  aged  forty- six,  des- 
^  cending  a  flight  of  stairs  in  haste,  fell,  and  luxated 


387 

Jier  right  foot  outwards,  the  tibia  inwards,  and  frac- 
tured the  fibula  near  to  the  lower  end. 

Her  cries  brought  assistance  to  her,  and  she  was 
carried  to  the  Hotel-Dieu.  Giraud,  who  then  officiated 
as  surgeon  in  chief,  visited  her,  and  discovered  that 
there  existed  both  a  luxation  and  a  fracture,  though 
most  of  the  signs  were  rendered  obscure  by  a  con- 
siderable swelling:  a  slight  echymosis  occupied  the 
back  of  the  foot,  and  severe  pains  were  experienced. 

Extension  on  the  foot,  and  counter- extension  on 
the  leg,  dislodged  the  parts  by  degrees  from  their  ac- 
cidental situations,  while,  by  the  process  of  confer- ^ 
mation,  the  surgeon  endeavoured  to  bring  them  into 
their  natural  ones.  This  was  soon  effected  without 
much  violence:  the  unfavourable  appearances  soon 
vanished;  the  pain  ceased;  an  apparatus  similar  to 
the  former  one  was  applied,  and  kept  wet  with  a 
strong  solution  of  common  salt^  instead  of  the  vege- 
to- mineral  water. 

In  the  evening,  the  pulse  being  full,  and  some- 
what raised,  a  moderate  blood-letting  was  deemed 
necessary.  Next  day,  the  apparatus  was  kept  con- 
stantly moist,  and  some  part  of  it  which  had  become 
relaxed  was  tightened.  The  pulse  continuing  full,  a 
low  diet  was  prescribed. 

Fifth  day,  the  apparatus  taken  off;  contact  be- 
tween the  bones  perfect :  a  yellowish  tinge  bespoke 
an  incipient  resolution  of  the  echymosis :  a  slight 
swelling  of  the  leg :  vesications  formed  on  the  part : 
these  are  opened  and  a  quantity  of  acrid  water  dis- 
charged from  them.  Sixth  day,  light  nourishment 
-allowed;  a  small  excoriation  of  the  heel,  which  is 


3^8 

dreissed  witTi  cerate  spread  on  la  linen  rag.  'SeveKt!i 
day,  regimen  less  strict;  no  bad  symptoms  super- 
Vene.  Eighth  day,  the  excoriation  enlarged;  same 
(dressing.  Teiith  day,  the  excoriation  become  fuh- 
]^ous:  caustic  is  applied  to  remove  it. 

Twenty-eighth  day,  the  discharge  frdm  the  leg 
decreased;  from  this  time  the  dressings  are  fenewed 
only  every  other  day.  Thirty- second  day,  the  ulcer 
ils  cicatrized :  no  pains  in  the  leg.  Thirty-ninth  day, 
fracture  of  the  fibula  firmxly  united:  ho  deformity 
remaining;  the  apparatus  is  laid  aside:  the  joint  re- 
mains stiff:  motions  performed  by  the  limb  difficult 
at  first,  but  become  gradually  more  free.  Forty- 
sixth  day,  symptoms  of  bile ;  gentle  evacuants.  Fifty- 
fourth  day,  the  patient  is  discharged  ciured,  except  a 
slight  impediment  in  walking,  which  exercise  will: 
soon  remove » 

12.  To  this  example,  I  might  add  many  others^ 
where  similar  displacements,  properly  treated,  termi- 
nated with  equal  success  •  no  pain;  no  swelling;  no 
inflammation;  arid  therefore,  of  course,  no  mortifi- 
cation. Yet  these  are  occurrences  of  which  authors 
speak,  as  if  they  were  the  usual  consequences  of  such 
luxations,  where,  to  a  violent  injury  done  to  the  soft 
parts,  is  added  a  fracture  near  to,  or  even  communi- 
cating with,^  a  joint.  The  eiToneous  opinions  of  the 
ancients  and  most  of  the  modems,  respecting  the 
dangers  arising  from  such  vicinity  or  communication, 
Ihave  contributed  liot  a  little  to  their  unfavourable 
prognosis  in  the  cases  under  consideration.  Should 
the  patient  survive  the  disease,  his  inevitable  lot,  ac- 
cording to  them^  must  be,  a  complete  anchylosis  of. 


380 

^e  leg  with  the  foot.  But,  the  preceding  cases  fully 
prove,  that  this  apprehension  is  unfounded.  A  con- 
siderable time  is  doubtless  necessary,  for  the  recovery 
bf  motion,  on  account  of  the  distension  and  rupture 
•^f  the  ligaments,  the  long  continued  inactivity  of  the 
-parts,  and  the  swelling  which  they  have  undergone. 
But  this  recovery  can  always  be  effected  by  means  of 
'exercise,  gentle  at  first,  increased  afterwards,  and 
regulated  according  to  the  principles  so  frequently 
laid  down  in  the  course  of  this  work.  Much  more  to 
be  relied  on  is  such  exercise,  than  the  long  catalogue 
of  discutient  means,  such  as  pumping  of  water  on  the 
parts,  alkaline  baths,  mineral  waters,  and  all  other 
external  applications>.  so  often  extolled  as  efficacious, 
and  so  often  found  entirely  useless. 

^        iiii. 

r 
LUXATION    OF     THE    FOOT,     COMPLICATED     BY     A 

SEPARATION   OF    THE    BONES   OF   THE    LEG,    AT 

THEIR  LOWER  END. 

Case  III.  (The  following  case  Vv^as  reported  by 
Thevenot).    I.  Joseph  Schneider,  an  ebonist,  aged 

^thirty- six,  as  he  was  walking  in  haste,  on  the  23d  of 
March,  1792,  fell  forward,  his  foot  being  forced  back- 
ward and  outward.    He  experienced  at  the  instant 

■  severe  pains  in  the  joint :  he  was  unable  to  rise,  and 
was  therefore  carried  home,  where  a  surgeon,  after 

'inaking  a  slight  extension,  applied  a  roller  on  the 

'  limb,  and  did  nothing  further.  The  patient  experi- 
enced no  relief.  The  pains  increased;  a  swelling 
supervened;  convulsive  motions  began  to  occur;  and 


390 

the  patient  was  brought  to  the  HoteLDieu,  six  days 
after  the  accident. 

From  the  deformity  of  the  foot,  Desault  immedi- 
ately discovered  that  it  was  luxated.  Its  point  was 
directed  outwards,  while  its  sole  was  turned  in  the 
same  direction :  beneath  the  malleolus  intemus,  which 
was  too  prominent,  was  a  tumour  formed  by  the 
astragulus.  The  crepitation  of  the  bones  which  was 
easily  heard,  the  preternatural  distance  between  the 
tibia  and  the  fibula,  the  mobility  of  this  latter  bone, 
and  the  absence  of  the  signs  of  a  fracture,  plainly 
showed  that  a  separation  of  the  two  bones  of  the  leg 
had  taken  place. 

A  reduction  was  immediately  effected  by  means 
of  extension  and  counter-extension,  and  was  an- 
nounced when  it  took  place  by  a  report  distinctly 
heard.  It  was  then  retained  by  a  bandage,  calculated 
to  answer  a  twofold  purpose ;  1st,  to  approximate, 
and  keep  together,  the  two  bones  of  the  leg :  2dly, 
to  secure  the  contact  and  immobility  of  the  bon.es  of 
the  foot. 

Blood-letting  was  prescribed:  an  anodyne  mix- 
ture administered;  low  diet;  in  the  night  severe 
pains  were  felt;  next  day,  they  were  increased;  on 
dressing  the  limb,  nothing  amiss  discovered;  ail  the 
parts  in  perfect  contact :  no  vestige  of  separation  be- 
tween the  tibia  and  the  fibula :  a  new  apparatus  ap- 
plied; and  kept  constantly  moist.  Third  day,  the 
patient  better:  fifth  day,  the  fibula  a  little  separated 
from  the  tibia :  the  circular  btmdage  drawn  tighter  to 
reduce  it  to  its  place  again.  Tenth  day,  every  thing 
in  its  natural  state:  no  pains:  swelling  gone,  Fif- 


391 

0- 

teenth  day,  a  simple  roller  substituted  in  place  of  the 

bandage  for  a  fracture  of  the  leg.  Nineteenth  day, 

the  patient  began  to  walk,  with  the  assistance  of  a 

stick:   twenty-third  day,  walks  easily :  twenty-eighth 

day,  is  dismissed  perfectly  cured,  and  neai'ly  free 

in  all  his  motions. 

13.  The  separation  of  the  bones  of  the  leg,  at 

their  lower  end,  does  not  constitute  a  very  serious 

complication  of  luxations  of  the  foot,  although  the 

contrary  is   asserted  by   several   authors.    Desault 

met  with  this  accident  several  times  in  the  course  of 

his  practice,  but  never  saw  it  terminate  otherwise 

than  favourably.  But  here,  as  in  all  other  cases,  the 

most  minute  attention  is  necessary  to  ensure  success, 

the  want  of  which  is  more  frequently  owing  to  the 

negligence  of  the  surgeon,  than  to  the  deficiencies 

of  the  art.  The  bandage  employed  after  reduction 

ought  to  act  principally  from  without  inwards,  and  in 

a  direction  perpendicular  to  the  axis  of  the  lower  part 

of  the  leg,  in  order  to  approximate  the  two  bones. 

It  will  be  of  some  service,  in  this  respect,  to  place 

on  each  bone  a  compress,  which,  projecting  more 

than  the  rest  of  the  circumference  of  the  limb,  will 

be  more  compressed,  and  on  that  account,  contribute 

to  the  end  in  view. 


50% 


IV. 


LUXATION  OF  THE  FOOT,  ACGOM-RANIRD  BV  A 
DISPLACEMENT  OF  THE  ASTRAGFLUS  AT  ITSt 
ARTICULATION   WITH   THE   OS   SCAPHOIDE. 

14.  Petit  never  met  with  n^ore  tlj£ia  two  iijstan- 
ces  of  that  displacement  of  the  astraguLus,  now  under 
consideration.  His  general  prognosis  on,  the  subject^ 
is  more  favourable  than  that  respecting  other  luxa- 
tions of  the  foot,  with  which  he  never  saw  t^ie  preseixt 
luxation  of  the  astragalus  complicated,  as  occurred, 
in  the  following  cases.  Had  such  complex  cas^ 
fallen  und,er  his  notice,  there  can  be  little  doubt,  but 
he  would  hixve  declared  amputation  to  be  the  op,^, 
resourse  of  art  on  die  occasion. 

But  the  experience  of  Desault  den^onstrates  to^ 
US  here,  as  well  as  in  the  preceding  cases,  the  gi^ea.t 
extent  to  which  we  ought  to  carry  our  confidence  in 
the  powers  of  nature,  when  skilfully  guided  by  th^ 
hand  of  art.  The  foUo^ying  case  was  communicate^ 
to  me  by  Leveiile. 

Case  IV.  John  Baptist  Landrin,  a  postilion,  aged 
thirty-six,  was  brought  to  the  Hote^-Dieu,  on  tl^^ 
19th  of  February,  1791. 

On  the  morning  of  the  same  day,  a  horse  on 
which  he  was  mounted  having  fallen,  his  foot  was 
caught  under  the  belly  of  the  animal.  As  soon  as  he 
was  disencumbered  of  the  vast  weight,  he  endea- 
voured to  rise,  but  in  vain.  The  pains  which  he  ex- 
perienced in  his  foot  were  extreme.  He  was  carried 
home,  where  some  surgeons,  having  ascertained  that 


593 

his  foot  was  luxated,  but  being  unable  to  reduce  it, 
sent  him  to  the  Hotel-Dieu. 

Desault  on  examing  him,  found  the  bones  of  his 
foot  to  be  situated  as  follows.  The  internal  pait  of 
the  OS  calcis  corresponded  to  the  lower  extremity  of 
the  tibia :  the  back  of  the  foot  was  directed  outwards, 
and  its  external  edge  downwards :  under  the  skin 
and  in  fi'ont  of  the  tibia  was  the  astragulus,  resting 
on  the  scaphoide  and  first  of  the  cuneiform  bones, 
where  it  formed  a  considerable  projection:  on  the 
back  of  the  leg,  the  fibula  corresponded  to  the  tendo 
Achillis.  The  pains  had  been  inconceivably  great 
from  the  moment  of  the  accident. 

Imboldened  by  numerous  instances  of  success 
in  similar  cases,  Desault,  notwithstanding  the  extent 
of  the  disease,  attempted  the  reduction.  One  assist- 
ant took  hold  of  the  superior  part  of  the  leg  to  make 
counter-extension,  and  another,  for  the  purpose  of 
extension,  grasped  the  metatarsus  with  one  hand,  and 
the  heel  with  the  other.  While  these  were  pulling  in 
different  directions,  the  surgeon  applying  his  thumb 
on  the  astragulus,  endeavoured  to  force  it  into  its 
place.  His  efforts  were  ineffectual :  the  opening 
through  the  capsule  of  the  astragulus  being  too  nar- 
row, would  not  suffer  it  to  pass.  Desault  perceiving 
this,  cut  through  the  integuments  which  covered  the 
bone,  and  having  laid  bare  the  capsule  and  the  liga- 
ments which  strengthen  it,  made  an  incision  into 
them  of  a  sufficient  extent,  taking  care  to  avoid  the 
tendon  of  the  tibialis  anticus,  which  vv^as  brought  into 
view.  The  openings  being  thus  enlarged,  admitted  of 
an  easy  reduction,  and  all  the  parts  resumed,  without 
difficulty,  their  natural  situation. 

51 


394 

The  reduction  being  effected,  the  wound  was 
closed,  and  covered  with  some  lint.  A  square  com- 
press was  then  placed  on  the  back  of  the  foot,  while 
a  long  one  was  applied  to  its  sole,  and  the  whole  se- 
cured by  an  apparatus  similar  to  that  described  in  the 
preceding  case.  The  patient  was  confined  to  a  very- 
strict  diet,  and  ordered  to  use  diluting  diinks. 

Next  day,  a  slight  bilious  diathesis ;  an  emetic 
in  solution  given;  apparatus  renewed.  Fourth  day, 
an  abscess  on  the  malleolus  externus  opened;  a  co- 
pious discharge  of  pus.  Eighth  day,  the  parts  in 
perfect  contact ;  a  favourable  discharge  from  the 
wounds;  dressings  applied  twice  a  day.  Fifteenth 
day,  a  general  oedema ;  aperient  ptisans  ordered. 
Twentieth  day,  the  oedema  gone:  a  bilious  diathesis 
returned :  in  consequence  of  this,  the  wounds  became 
pale:  another  emetic  given.  Twenty- seventh  day, 
a  very  painful  excoriation  occurred  on  the  heel :  care 
taken  not  to  let  the  foot  rest  on  that  pait,  as  the  sore 
appeared  to  be  the  effect  of  compression.  Thirtieth 
day,  the  wounds  in  a  favourable  way :  all  the  bones 
in  exact  contact.  Fortieth  day,  appai'atus  laid  aside, 
and  a  simple  roller  substituted  in  its  place :  wounds 
already  cicatrizing.  Fiftieth  day,  the  limb  put  in 
gentle  motion,  which  is  gradually  increased  every 
day.  Same  dressing  continued  till  the  eightietii  day : 
v/ounds  not  yet  cicatrized.  Hundred  and  t^^enty- 
seventh  day,  a  considerable  swelling  around  the  joint : 
a  splinter  made  its  ^^ay  out,  and  was  followed  in  a 
few  days  by  several  more.  In  the  fifth  month  an  ab- 
scess formed  on  the  heel,  from  which,  when  opened, 
another  splinter  escaped.  In  the  mean  time,  the  pa- 
tient left  the  Hotel-Dieu.  During  his  absence  more 


395 

splinters  were  discharged.  Returning  about  a  year 
afterwards  with  a  small  ulcer,  he  was  dismissed  again 
in  a  short  time,  perfectly  cured,  except  a  slight  stiff- 
ness of  the  joint. 

15.  The  reduction  of  this  luxation  of  the  foot  pre- 
sents a  difficulty  worthy  of  the  attention  of  practiti- 
oners, as  well  on  account  of  its  own  nature,  as  in  con- 
sideration of  the  process  which  was  employed  on  the 
occasion :  I  allude  to  the  narrowness  of  the  opening 
in  the  capsule.  I  mentioned,  on  a  former  occasion, 
the  obstacles  sometimes  created  by  this  circumstance 
to  the  reduction  of  luxations  of  the  os  humeri  and 
the  OS  femoris.  It  was  impracticable  in  the  present 
to  enlarge  the  opening  in  the  capsule,  as  could  be  done 
in  those  cases,  by  moving  the  head  of  the  bone  in  all 
directions^;  because  the  bone  was  too  small  to  afford 
any  purchase  to  the  surgeon.  The  only  resource  was, 
the  use  of  the  knife;  and  the  operation  was  the  more 
easily  performed,"  on  account  of  the  capsule  being 
situated  immediately  beneath  the  integuments,  from 
which  circumstance  it  could  be  the  more  speedily 
brought  into  view. 

16.  The  apprehension  of  mischief  resulting  from 
the  admission  of  air  to  the  articulating  surfaces^  would 
no  doubt,  in  this  case,  have  restrained  most  practiti- 
oners :  but,  even  supposing  this  apprehension  to  be 
well  founded,  ought  it  to  deter  the  surgeon  from 
adopting  the  only  possible  mean  of  effecting  a  reduc- 
tion, and  of  thus  putting  an  end  to  the  alarming  state 
of  things  aiising  from  the  displacement  of  the  bones? 
Desault  proved  in  numerous  instances,  that  the  appre- 
hensions of  authors  respecting  such  cases  have  been 


S9Q 

greatly  exaggerated,  and  that  it  is  practicable  to  cure 
^vounds  that  penetrate  into  the  cavities  of  joints, 
in  the  same  manner  as  if  they  were  simple  wounds, 
and  with  but  very  little  more  danger  to  the  patient. 
Yet  it  would  seem,  that  the  tediousness  of  the  cure 
and  the  exfoliation  of  the  bones,  arose,  in  the  present 
case,  from  the  opening  made  into  the  joint,  and  per- 
haps also,  in  part,  from  the  disposition  and  habit  of 
the  patient.  Finally,  in  those  alarming  injuries  of  the 
joints,  unconnected  with  external  wounds,  where 
practitioners  have  looked  to  no  resource  but  that  of 
amputation,  Desault  has,  in  a  short  time,  and  without 
any  dangerous  occurrence,  restored  to  the  subjects 
the  free  use  of  their  limbs.  The  following  case, 
drawn  up  by  Plaignault,  is  a  proof  of  this. 

Case  V.  Pierre  Phipe,  aged  twenty-four,  fell, 
on  the  20th  of  February,  1788,  from  an  elevation  of 
more  than  twenty  feet :  lighting  on  his  foot,  he  turned 
it  outwards,  sunk  instantly  to  the  ground,  and  was 
unable  to  rise  again.  He  was  carried  home,  and  from 
thence  to  the  FIotel-Dieu. 

Desault  examining  him  on  his  arrival,  discovered 
a  luxation  of  the  foot  outwards,  and  of  the  astragulus 
forwaixl  and  upward :  the  patient's  sufferings  were 
great.  Convinced  that  the  most  effectual  method  to 
relieve  these  was  to  reduce  the  luxation,  the  surgeon 
undertook  it  immediately,  pushed  the  astragulus  into 
its  place  without  difficulty,  and  with  a  report  which 
was  heard  by  every  one  present,  while  the  bones  of 
the  foot  were  brought  into  their  proper  situation  by 
means  of  extension.  In  an  instant  the  pains  vanish- 
ed and  the  motions  of  the  foot  became  easy.    The 


397 

necessary  apparatus  was  applied.  The  activity  of  the 
pulse  called  for  blood-letting,  which  was  immediately 
performed.     A  low  diet  was  prescribed. 

On  the  two  following  days  blood-letting  was  re- 
peated, both  on  account  of  the  active  state  of  the 
pulse,  and  of  a  considerable  swelling  which  took 
place  *.n  the  joint.  The  apparatus  was  kept  constant- 
ly wet  with  vegeto-mineral  water.  Eighth  day, 
somewhat  better:  echymosis  gone.  Fifteenth  day, 
the  apparatus  laid  aside.  From  this  time  the  foot  was 
gently  moved  every  day.  Eighteenth  day,  the  pa- 
tient able  to  stand  on  the  affected  foot  without  pain. 
Twenty-sixth  day,  walks  with  the  assistance  of  a 
staff.  Thirty-ninth,  walks  without  limping,  and  en- 
joys all  the  motions  of  the  foot.    Discharged. 

§  V. 

LUXATION  OF  THE  FOOT,  COMPLICATED  WITH  AN 
ESCAPE  OF  THE  ASTRAGULUS,  THROUGH  THE 
CAPSULE  AND  THE  LACERATED  INTEGUMENTS. 

17.  When,  in  a  luxation  of  the  foot,  the  integu- 
ments, capsule,  and  ligaments  are  so  lacerated,  as  to 
suffer  the  astragulus  to  escape,  it  would  oftentimes  be 
imprudent  to  attempt  its  reduction,  as  was  done  in 
the  preceding  cases.  The  violence  already  done  to 
the  parts  around  the  joint  is  excessive;  but  this 
would  be  increased  by  the  extension,  and  other 
efforts  necessary  in  reduction.  V/hatever  cai'e  might 
be  taken,  it  would  be  difficult  to  prevent  a  vast 
swelling,  long  continued  pains,  and  perhaps  even  a 
caries  of  the  bone  exposed  to  the  air,  with  all  those 


398 

sufferings  and  dangers,  to  which  such  an  accident 
gives  origin.  In  such  a  case  all  the  bones  of  the 
foot  have  been  known  to  become  carious,  a  state  of 
things,  which  calls  for  the  ultimate  resources  of  art, 
and  draws  after  it  a  train  of  evils,  which  it  is  always 
of  the  utmost  importance  to  prevent. 

18.  What  means  are  then  to  be  employed?  Two 
expedients  only  remain.  1st,  the  amputation  of  the 
foot;  2dly,  the  extirpation  of  the  astragulus.  The 
first  is  a  cruel  resource,  which  should  never  be 
adopted  but  in  the  last  extremity,  because  it  deprives 
the  patient  of  a  portion  of  himself,  necessary  to  the 
performance  of  liis  functions.  But  the  measure  is 
forbidden  by  a.  reason  still  more  powerful.  Amidst 
the  general  disorder  of  the  system,  the  severe  pains 
experienced  by  the  patient,  the  convulsions,  and  the 
delirium  which  oftentimes  exists,  what  ground  has 
the  surgeon  to  hope  for  success?  Will  not  the  ope- 
ration add  to  the  number  of  these  alarming  appear- 
ances? Will  it  not  aggra-s'ate  them?  May  it  not 
render  them  fatal?  Both  reason  and  experience  reply 
in  tlie  affirmative. 

19.  In  such  a  case,  then,  the  extirpation  of  the 
astragulus  is  the  expedient  to  be  preferred.  What, 
indeed,  are  its  inconveniences?  1st,  An  inevitable 
anchylosis  of  the  foot  and  leg:  2dly,  a  shortening  of 
the  affected  limb.  But  a  leg  even  in  this  state,  is  still 
better  than  a  wooden  leg,  which  is  the  necessary  con- 
sequence of  amputation :  besides,  a  leg  of  tlie  former 
description  occasions  no  great  inconvenience  in  either 
walking  or  standing,  whereas  one  of  the  latter,  pro- 
duces extreme  lameness :  in  the  first  case,  a  heel  on 


699 

the  aiFected  side  somewhat  higher  than  that  on  the 
other,  is  an  easy  method  of  removing  the  deformity. 
What,  then,  are  such  trifling  disadvantages,  when 
compared  with  the  evils  which  they  ward  off?  The 
extirpation  of  the  astragulus  is  accompanied  with  but 
little  pain.  The  want  of  this  intermediate  body  be- 
tween the  leg  and  the  foot,  by  producing  a  relaxation 
of  the  surrounding  soft  parts,  prevents  pain  and  swell- 
ing in  such  cases :  should  abscesses  supervene,  they 
v/ill  not,  if  properly  treated,  greatly  retard  the  cure. 
In  a  word,  experience  coincides  with  this  doctrine. 
Desault  has  seen  it  twice  verified  in  the  practice  of 
other  surgeons,  and  tliree  times  in  his  owTi.  I  have 
known  of  but  one  case  of  the  kind,  in  which  the  ter- 
mination M^as  fatal,  and  there,  a  malignant  fever,  in- 
duced by  the  contaminated  air  of  the  hospital,  cer- 
tainly contributed  to  the  death  of  the  patient,  which 
did  not  occur  till  two  months  after  the  reduction. 

Case  VI.  Desault  usually  gave  in  his  lectures, 
the  history  of  a  case  where  the  success  of  this  prac- 
tice was  remarkable.  A  man  was  brought  to  the 
Hotel-Dieu,  with  a  luxation  of  the  foot,  complicated 
with  a  fracture  of  the  lower  part  of  the  leg,  and  a 
laceration  of  the  ligaments  and  capsule,  through 
which  tlie  astragulus  had  escaped  by  a  luxation  for- 
ward and  upward,  so  as  to  have  half  of  its  anterior 
surface  exposed.  The  extent  of  the  injury  seemed 
to  call  for  amputation.  But  the  youth,  the  vigour, 
and  sound  constitution  of  the  patient,  gave  ground  to 
hope  that  a  process  less  desperate  might  succeed. 
The  astragulus,  already  separated  anteriorl}'-,  was 
extracted  by  dividing  the  attachments  w^hich  held  it 


400 

to  the  o3  calcis,  and  the  bones  of  the  leg:  the  reduc- 
tion was  then  effected  without  diificulty.  The  parts  be- 
ing replaced  more  readily  in  consequence  of  the  remo- 
val of  this  bone,  were  retained  so  by  means  of  a 
bandage  similar  to  that  for  fractures  of  the  leg,  but 
modified  so  as  to  suit  the  particular  case.  The  pa- 
tient lost  blood  once  or  twice :  the  apparatus  was 
kept  constanly  wet ;  a  very  strict  regimen  v^^as  pre- 
scribed for  some  days;  but  fevv^  troublesome  symp- 
toms occurred;  a  slight  swelling  took  place,  but  was 
soon  removed;  a  favourable  suppuration  came  on; 
the  dressing  was  renewed  twice  a  day ;  some  splinters 
escaped  occasionally ;  several  abscesses  formed  suc- 
cessively were  opened,  and  healed  up  again:  the 
wounds  themselves  closed,  and  the  patient  finally 
recovered,  with  an  anchylosis,  indeed,  between  the 
foot  and  leg,  and  a  limb  a  little  shorter  than  natural, 
but  which  still  served  the  purposes  of  walking  and 
standing. 

20.  To  this  example,  I  might  add  those  of  other 
patients  treated  at  the  Hotel- Dieu,  in  the  same  man- 
ner and  with  equal  success.  But  what  purpose  would 
such  an  accumulation  of  facts  answer?  It  would  only 
fatigue  the  reader  without  adding  to  his  conviction. 

21.  If  the  injury  accompanying  the  luxation  be  so 
extensive,  as  to  destroy  the  principal  blood-vessels, 
and  leave  no  hope  of  saving  the  limb,  amputation 
becomes  then  the  only  resource,  and  the  case  as- 
sumes a  resemblance  to  those  v/here  the  limbs  are 
shattered  by  cannon  balls :  the  success  then  depends 
veiy  much  on  the  strength  or  weakness  of  the  pa- 
tient. 


401 

Case  VII.  A  man  fell  fi-om  a  carriage :  his  foot 
becoming  entangled  between  the  spokes  of  the  wheel, 
was  almost  separated  from  the  leg.  It  adhered  only 
by  a  small  portion  of  skin  behind,  and  by  the  tendons 
of  the  muscles  which  run  to  the  toes  both  above  and 
below. 

Desault  was  called  to  the  patient,  wlxim  he  found 
in  a  most  deplorable  state :  the  pains  which  he  suffer- 
ed were  excruciating:  the  parts  around  the  wound 
were  greatly  swollen ;  a  general  spasm  affected  the 
system :  amputation  was  judged  necessary,  but  was 
deferred  till  the  symptoms  should  be  mitigated.  The 
limb  was  diessed :  next  day,  a  gangrene  began  to 
affect  the  foot,  which  was  then  sepai'ated  from  the 
leg  by  cutting  the  tendons :  the  ends  of  the  tibia  and 
fibula  exfoliated;  the  wound  healed,  and  the  patient 
now  enjoys,  in  part,  the  functions  and  uses  of  the  leg, 
by  means  of  an  artificial  foot,  framed  and  fitted  on  by 
an  ingenious  mechanic.  Had  the  limb  been  too 
hastily  amputated  while  the  patient  was  affected  with 
general  spasms,  fatal  consequences  would  probably 
have  ensued. 


.^-2 


APPENDIX. 


ARTICLE  I. 


The  following  interesting  paper,  extracted  from 
the  Medical  Repository,  Hexad:  ii.  vol.  i.  p.  122.... 
124,  will  give  the  reader  a  better  idea,  than  he  can 
receive  from  any  other  source,  of  Dr.  Physick's  new 
and  successful  method  of  treating  an  old  and  obsti- 
nate fracture  of  the  os  humeri. 

A  Case  of  Fracture  of  the  Os  Humeri^  in  which  the 
broken  ends  of  the  bone  not  uniting  in  the  usual 
manner^  a  cure  was  effected  by  means  of  a  seton. 
Communicated  to  Dr.  Miller  by  Philip  S.  Phy- 
sick,  M.  D. 

"  Isaac  Patterson,  a  seaman,  twenty-eight  years  of 
age,  applied  to  me  in  May,  1802,  in  consequenpe  of 
a  fracture  of  his  left  arm,  above  the  elbow  joint,  which 
had  taken  place  several  months  before ;  but  the  ends 
of  the  bone  not  having  united,  rendered  his  arm  nearly 
useless  to  him. 

"  The  history  he  gave  me  w^as,  that  on  the  11th 
of  April,  1801,  after  having  been  at  sea  seven  months, 
his  arm  was  fractured  by  a  heavy  sea  breaking  over 
the  ship.  Nothing  was  done  for  his  relief  until  next 
day,  when  the  captain  and  mate  bound  it  up,  and  ap- 
plied splints  over  it.  No  swelling  supervened,  nor 
did  he  suffer  any  pain.  Three  weeks  after  this  acci- 


404 

dent,  he  arrived  at  Alexandria,  when  the  state  of  the 
arm  was  examined  by  a  physician,  who  told  him,  that 
the  ends  of  the  bone  were  not  in  a  proper  situation. 
After  making  an  extension,  the  spUnts  and  bandages 
were  again  appHed.  He  remained  in  Alexanekia  four 
months,  when,  finding  his  arm  no  stronger,  he  left 
off  all  dressings^  and  went  on  board  tire  New- York 
frigate  as  steward :  iii  this  capacity  he  remained  near 
the  Federal  City  six  nionths,  and  by  being  under  the 
necessity  of  using  his  arm  as  much  as  possible,  he 
found  the  connexion  between  the  ends  of  the  bones 
became  looser  and  looser,  tilly  at  length,  the  arm  bent 
as  easily  as  if  a  nev/  joint  had  been  formed  at  the 
place  of  the  fracture^  From  the  frigate  he  went  ta 
Baltimore,,  where  an  attempt  was  made  by  machinery 
to  extend  the  arm,  and  keep  the  ends  of  the  bone  in 
apposition,  by  continuing  the  extension.  Under  this, 
treatment  he  remained  two  months,  but  experiencing 
no  benefit,  he  was  advised  to  come  to  Philadelphia. 
'  '^'On  examining  the  arm,  I  found  that  the  humerus 
had  been  fractured  about  two  inches  and  a  half  above 
the  elbow  joint^  andthat  the  ends  of  the  bone  had  pas- 
sed each  other,  about  an  inch :  the  lower  fragment,  or 
that  nearest  the  elbow,  was  situated  over,  and  on  the 
outside  of  the  upper  portion  of  the  bone.  The  con- 
nexion that  existed  between  the  ends  of  the  humerus 
was  so  flexible,  as  to  allow  of  motion  in  every  direct 
tion',  and  by  forcible  extension,  the  lower  end  might 
be  pulled  down  considerably,  but  never  sa  low  as  to 
be  on  a  line  with  the  end  of  tlie  upper  extremity.  He 
was  admitted  into  the  Fennsylvania  hospital,  the  lat* 
ter  end  of  May ;  but  tlie  weather  becoming  very  hot^ 


405 

it  was  judged  best  to  defer  any  operation  that  might 
l3e  necessary,  until  the  fall  of  the  year.  Unfortunately 
he  then  contracted  a  bilious  fever,  of  which  he  was 
so  ill,  that  his  life  was  despaired  of  for  some  days. 
From  this  fever  his  recovery  was  so  slow,  that  it  was 
not  thought  proper  to  perform  any  operation  until 
December.  It  still  remained  to  decide,  by  what 
means  a  bony  union  of  the  humerus,  might  most  pro- 
bably be  effected.  In  the  year  1785,  when  a  student, 
I  had  seen  a  case  in  our  hospital,  similar  to  this  in 
eveiy  essential  circumstance,  in  w^hich  an  incision 
was  made  down  to  the  extremities  of  the  fractured 
bone,  which  were  then  sawed  off,  thereby  putting 
the  parts  into  the  condition  of  a  recent  compound 
fracture.  No  benelit,  however,  was  derived  from 
this  painful  operation,  and  some  months  afterward 
the  arm  was  amputated.  This  case  had  made  a 
strong  impression  on  my  mind,  and  rendered  me  un- 
willing to  perform  a  similar  operation.  I  therefore 
proposed  to  some  of  the  medical  gentlemen  of  the 
hospital,  who  attended  in  consultation,  that  a  seton- 
needle,  armed  with  a  skein  of  silk,,  should  be  passed 
through  the  arm,  and  between  the  fractured  extremi- 
ties of  the  bone,  and  that  the  seton  should  be  left  in 
this  situation,  until  by  exciting  infkmmation  and  sup- 
puration, granulations  should  rise  on  the  ends  of  the 
bone,  which  uniting  and  afterwards  ossifying,  w^ould 
form  the  bony  union  that  was  wanting.  This  opera- 
tion being  agreed  to,  it  was  performed  on  the  18th  of 
December,  1802,  twenty  months  after  the  accident 
happened.  Before  passing  the  needle,  I  desired  the 
assistants  to  make  some  extension  of  the  arm,  in  or- 


406 

der  that  the  seton  might  be  introduced  as  much  as 
possible  between  the  ends  of  the  bone.  Some  lint 
and  a  pledget  were  applied  to  the  orifices  made  by  the 
seton-needle,  and  secured  by  a  roller.  The  patient 
suffered  very  little  pain  from  the  operation.  After  a 
few  days  the  inflammation  (which  was  not  greater 
than  what  is  commonly  excited  by  a  similar  operation 
through  the  flesh,  in  any  other  part)  was  succeeded 
by  a  moderate  suppuration.  The  arm  was  now  again 
extended,  and  splints  applied.  The  dressings  were 
renewed  daily  for  twelve  weeks,  during  which  time 
no  amendment  was  perceived;  but  soon  afterwards 
the  bending  of  the  arm  at  the  fracture  was  observed  to 
be  not  so  easy  as  it  had  been,  and  the  patient  com- 
plained of  much  more  pain  than  usual  whenever  an 
attempt  was  made  to  bend  it  at  that  place.  From  this 
time,  the  formation  of  the  new  bony  union  went  on 
rapidly,  and,  on  the  fourth  of  May,  1803,  was  so 
perfectly  completed,  that  the  patient  could  move  his 
arm,  in  all  directions,  as  well  as  before  the  accident 
happened  The  seton  was  now  removed,  and  the 
small  sores  occasioned  by  it,  healed  up  entirely  in  a 
few  days.  On  the  28th  May,  1303,  he  was  dischai'g- 
ed  from  the  hospital;  perfectly  well,  and  he  has  since 
repeatedly  told  me  that  his  arm  is  as  strong  as  it 
ever  was." 

To  the  preceding  paper  it  is  unnecessary  to  add, 
that  the  mode  of  treatment  there  stated  might  be 
adopted  in  similar  fractures  of  other  bones,  provided  a 
seton-needle  could  be  passed  near  to  the  ends  of  the 
fragments,  without  any  risque  of  wounding  blood- 
vessels, nerves,  or  other  parts  of  importance.  It  is 


407 

thus  that  solitary  facts  minutely  detailed  and  well 
substantiated,  oftentimes  grow  into  principles  of  ex- 
tensive application. 

ARTICLE  11. 

An  account  of  Dr.  Physick^s  imprcDement  of  De- 
saulfs  apparatus  for  making  permanent  extension 
in  oblique  fractures  of  the  osfemoris. 

Dr.  Physick  having  observed  that  in  the  appli- 
cation of  Desault's  apparatus,  the  patient  was  some- 
times injured  by  the  pressure  of  the  strap  or  roller 
gg  (plate  2)  which  passes  under  the  tuberosity  of 
the  ischium  for  the  purpose  of  making  counter-ex- 
tension, devised  the  following  method  of  remedying 
this  inconvenience,  in  which  he  succeeded  to  his 
wishes. 

He  directed  the  upper  end  of  the  long  external 
splint  to  be  formed  like  the  head  of  a  crutch,  and  the 
splint  itself  to  be  lengthened  so  as  to  reach  and  bear 
against  the  axilla  of  the  aflPected  side,  which  must 
be  well  defended  from  pressure  by  a  bolster  of  flan- 
nel or  some  other  soft  material.  By  this  expedient 
the  Dr.  evidently  formed  two  points  of  counter-ex- 
tension, instead  of  one,  as  is  the  case  in  the  apparatus 
of  Desault.  Between  these  two  points,  namely,  the 
axilla  and  the  perineum,  the  same  quantity  and  force 
of  pressure  is,  by  Dr.  Physick's  improvenuent,  dii}i~ 
dedy  which,  in  the  original  apparatus  of  Desault,  is 
borne  by  the  perineum  alone.  The  risque  of  exco- 
riation and  injury  to  the  patient,  then,  in  the  former 


408 

case,  is  to  that  ^vhich  he  runs  m  the  latter,  t)nly  as 
one  to  two,  or  nearly  so.  As  it  is  no  less  the  duty  of 
the  surgeon  to  pre\'ent  suffering  than  it  is  to  remove 
deformity  or  to  save  life,  Dr.  Physick  has  ceitainly  in 
this  respect  made  an  important  step  in  the  advance- 
ment of  his  profession. 

But  there  is  still  another  advantage  derived  from 
the  lengthening  of  tlie  external  splint.  In  the  original 
apparatus  of  Desault,  the  strap  ^^  intended  for  coun- 
ter-extension, by  passing  no  higher  up  than  the  spine 
of  the  ilium,  runs  too  much  across,  and  therefore 
acts  too  much  on,  the  upper  pait  of  the  thigh*  By 
this  it  not  only  irritates  the  muscles  of  the  part,  and 
induces  them  to  contract,  but  also  tends  to  draw  the 
upper  fragment  of  the  os  femoris  a  little  outward,  and 
thus  to  render  the  thigh  in  some  measure  deformed. 
But,  in  the  improvement  of  Dr.  Physick,  the  strap 
gg  is  secured  in  a  mortise  cut  in  the  external  splint, 
about  midway  between  the  spine  of  the  ilium  and 
the  axilla.  This  strap,  by  being  thus  carried  higher 
up  on  the  body,  does  not  run  across  the  thigh  at  all. 
It  consequently  presses  on  and  irritates  the  muscles 
much  less,  acts  more  in  the  direction  of  the  os  femo- 
ris, and  has  no  tendency  to  draw  the  superior  frag- 
ment outward. 

Hence  this  improvement  not  only  diminishes  the 
patient's  sufferings,  but  gives  him,  perhaps,  the  best 
possible  chance  of  having  his  limb  preserved  free 
from  deformity* 

Another  improvement  made  on  the  lower  end  of 
the  external  splint  by  Dr.  James  Hutchinson  de- 
serves also  to  be  mentioned.    It  was  found  that  in 


the  original  apparatus  of  Desault,  the  strap  or  roller 
L  (plate  2)  used  for  the  purpose  of  extension,  had  a 
tendency  to  draw  the  foot  too  much  outward.  This 
fault  Dr.  Hutchinson  very  ingeniously  remedied,  by 
attaching  to  the  lower  part  of  the  external  splint,  a 
little  above  the  mortise,  a  small  block  extending  in- 
wardly, at  a  right  angle  with  the  splint,  so  far  as  to 
be  on  a  line  with  the  middle  of  the  sole  of  the  foot. 
Over  the  end  of  this  block,  in  which  a  notch  is  cut 
to  receive  them,  the  ends  of  the  strap  L  are  carried, 
previously  to  their  being  secured  to  the  external 
splint.  By  means  of  this  expedient  extension  is 
made  precisely  in  the  direction  of  the  limb,  and  the 
inconvenience  of  drawing  the  foot  outward  is  com- 
pletely obviated. 

Thus  improved  by  Drs.  Physick  and  Hutcliin- 
son,  the  apparatus  of  Desault  for  oblique  fractures  of 
the  OS  femoris,  leaves,  perhaps,  scarcely  a  remaining 
desideratum  on  the  subject. 

.      '  ARTICLE  III. 

EXPLANATION  OF  THE  THIRD  PLATE. 

This  plate  gives  a  full  view  of  an  apparatus  for 
making  permanent  extension,  in  oblique  fractures  of 
the  leg,  when  both  bones  are  broken.  This  appara- 
tus was  first  devised  and  constructed  several  years 
ago,  by  Dr.  James  Hutchinson,  then  a  pupil  in  the 
Pennsylvania  hospital,  and  is  now  in  general  use 
among  the  practitioners  of  Philadelphia. 

Fig.  1.  Represents  the  leg  and  foot,  with  the  ap- 
paratus applied. 

53 


410 

A.  A  common  roller,  passed  several  times  round 
the  leg  a  little  below  the  knee,  on  which  counter-ex-  ' 
tension  is  made. 

B.  A  silk  handkerchief  folded,  or  a  strong  roller 
made  of  soft  muslin,  passed  once  round  the  leg,  just 
above  the  ancle,  from  behind  forwaiti.  C.  The 
place  where  its  two  ends  cross  each  other  to  pass 
down  along  each  side  of  che  foot,  as  seen  at  ^,  to  D, 
where  they  are  secured  by  a  knot  drawn  but  moder"- 
ately  tight,  a  a.  The  same  ends  cominucd  to  E 
where  they  are  again  secured  by  a  firm  knot  over  the 
cross  piece  F,  which  passes  between  the  two  strong 
splints  G  G,  that  run  on  each  side  of  the  leg  from  a 
little  above  the  knee,  to  the  distance  of  four  or  five 
inches  beyond  the  sole  of  the  foot.  This  is  the  ban- 
dage by  which  extension  is  made,  as  will  be  men- 
tioned hereafter. 

H.  Two  bits  of  strong  tape,  each  about  two  feet 
long,  placed  in  the  longitudinal  direction  of  the  leg, 
and  firmly  secured  by  the  roller  A,  which  passes 
over  their  middle.  Two  such  bits  of  tape,  are  thus 
applied  on  each  side  of  the  leg,  and  their  four  ends, 
passing  tlirough  four  holes  in  the  upper  end  of  each 
of  the  splints  G  G,  are  secured  on  their  outsides  by 
firm  knots  as  represented  at  H. 

Fig.  2.  A  view  of  one  of  the  splints  G  G,  separ- 
ated fi'om  die  leg. 

a.  The  four  holes  in  the  upper  end,  through 
which  the  bits  of  tape  H  pass. 

b.  The  mortise  in  the  lower  end,  which  receive^ 
the  cross-piece  F, 


411 

Fig.  3.  A  view  of  the  cross-piece  F,  \Yhich  must^ 
be  firmly  fixed  in  one  of  the  splints  G  G,  but  move- 
able in  the  mortise  of  the  other,  so  that  the  splints 
may  be  taken  asunder  at  pleasure. 

The  following  is  the  method  of  applying  this  ap- 
paratus. 

While  extension  and  counter-extension  are  made 
by  two  assistants,  the  surgeon  placing  the  bits  of 
tape  H  on  each  side  of  the  leg,  secures  them  firmly  by 
the  roller  A  applied  round  the  limb,  with  a  proper 
degree  of  tightness.  He  then  applies  the  middle  of 
the  handkerchief  or  roller  B  on  the  tendo  Achiilis, 
brings  its  ends  across  each  other,  before  the  leg  at 
C,  and  carrying  them  down  along  each  side  of  the 
foot,  secures  them  by  a  knot  at  D.  Letting  go  the 
ends  of  the  handkerchief  B,  he  next  places  on  each 
side  of  the  leg  the  splints  G  G,  connects  them  at  the 
lower  end  by  the  cross-piece  F  and  secures  them  at 
the  upper  end  by  the  tapes  H.  He  then  resumes 
the  ends  of  the  handkerchief  B,  carries  them  down- 
ward as  seen  ^t  a  a  and  secures  them  by  a  firm  knot 
at  E  round  the  cross-piece  F. 

From  this  view  and  explanation  of  the  apparatus 
Fig.  1,  I  presume  its  construction,  application,  and 
mode  of  operation  will  be  very  easily  understood.  It 
is  unnecessary  therefore  to  add,  that  the  extension 
and  counter-extension  made  on  the  limb,  will  be 
directly  proportioned  to  the  degree  of  force  with 
which  the  ends  a  a  of  the  handkerchief  B  are  dra^^oi 
bver  the  cross-piece  F.  As  action  and  reaction,  in 
this  case,  must,  as  in  all  others,  be  equal,  the  splints 
G  G  will  be  pushed  upward  by  the  ends  of  the  hand- 


4i^ 

kefishief  B  with  precisely  the  same  force  that  is 
applied  on  these  ends  to  draw  the  foot  and  lower 
fragments  do^vnward.  Hence  the  counter-extension 
made  above  on  the  roller  A  will  be  exactly  equal  to 
the  extension  made  below  by  the  handkercliief  B. 

I  ought  to  have  observed,  that  it  is  necessary  to 
defend  the  soft  paits,  both  above  and  below,  from 
the  pressure  of  the  estcndbig  and  counter- extending 
straps,  by  means  of  soft  compresses  applied  next  to 
the  skin.  This  is  particulaiiy  necessaiy  on  the  instep 
C  where  the  ends  of  the  handkerchief  B  cross  each 
other.  It  requires  some  attention  on  the  part  of  the 
surgeon  to  prevent  this  spot  from  being  excoriated, 
especially  if  it  be  found  necessary  to  make  a  forcible 
extension. 

If  the  fracture  be  simple,  a  bandage  of  strips  pre- 
viously applied  round  the  hmb  from  the  ancle  to  the 
knee  is  highly  useful.  It  secures  the  fi^gments  more 
effectually  from  lateral  displacement,  and  prevents 
the  swelling  of  the  leg.  A  simple  roller  applied  with 
a  moderate  degree  of  tightness  round  the  foot,  is  also 
of  service  in  preventing  a  swelling  in  that  part,  as 
well  as  in  removing  it  if  it  has  already  occurred. 

This  apparatus  is  still  more  strikingly  useful  in 
compound  fractures,  on  account  of  the  facility  with 
which  it  enables  the  surgeon  to  apply  the  necessary 
dressings.  These  can  be  rene-^^ed  as  often  as  may 
be  requisite,  without  giving  the  patient  the  least 
pain,  without  discontinuing  extension,  or  in  any 
measure  whatcv^er  deranging  the  fragments.  The 
surgeon  can  also,  in  all  cases,  discover  by  a  single 
glance  of  his  eye,  whether  or  not  the  fragments  are 


413 

in  proper  apposition.  It  is  right  to  secure  the  whole 
apparatus  by  three  bits  of  tape  passed  round  it, 
similar  to  those  tied  round  the  leg  in  the  apparatus 
for  fractures  of  the  thigh,  as  represented  in  plate  2. 

I  shall  only  add,  that  the  surgeon  must  employ 
such  bolsters  and  compresses  as  he  may  find  neces- 
sary to  support  the  limb,  and  protect  it  from  undue 
pressure,  and  that  he  must  be  vigilant  to  prevent,  by 
frequent  examinations,  the  extending  and  counter- 
extending  straps  from  becoming  relaxed. 

For  a  few  further  remarks  on  the  subject  of  this 
apparatus,  the  reader  is  referred  to  a  paper  published 
by  Dr.  Hutchinson,  in  the  second  number  of  the 
Philadelphia  Medical  Museum. 


FINIS, 


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